Harries, AD

Jaggi, P

English

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78 Unusual cause of Coma P Jaggi, AD Harries Introduction Confusion and reduced levels of consciousness are a common cause of admission to medical wards. The differential diagnosis is long and varied, but it is always satisfying (both for the clinician and the patient) to identify a potentially treatable caulie of the illness. We present an unusual cause of cqma, which after diagnosis and treatment resulted in complete recovery of the patient. Case report A 40 year old Malawian woman was admitted to hospital in coma. A few days before admission she had felt tired, and had been given iron tablets and anti-helminthics. The day before admission she had been febrile and had taken chloroquine 600 mg base. On the day of admission she had been found unconscious by her relatives. Examination revealed a well nourished woman with normal hydration status who was in deep coma. The general examination was normal, and there were no neurological latera-lising signs. Initial investigations showed: thick film for ma-laria parasites negative; blood glucose 48 mgl dl; serum sodium 129 mEqlI; serum potassium 4.0 mEqlI; CSF was clear fluid with no white cells, protein 25 mgl dl, glucose 25 mgl dl. Initial management consisted of an intravenous bolus of 50% glucose. She regained consciousness, but remained confused and uncommunicative. Over the following 5 days, despite a continuous dextrose infusion, she had recurrent symptomatic hypoglycaemia which responded only temporarily to bolus doses of 50% dextrose. On the 6th day of admission she was sufficiently awake and co-operative to give a history. One year previously she had delivered her 5th child by Cae-Seventh Day Adventist Hospital, Blantyre P Jaggi, AD Hanies Conespondence to: Dr. PeterJaggi Physician Seventh O'!y Adventist Hospital Blantyre Malawi Malawi Medical Joumal. July 199'2. VoL 8. No. '2 sarean section. She had breast fed the other four children, but produced no milk for her 5th child. She failed to menstruate following delivery, and noticed loss of axillary hair. The main features on examination were: puffy face; slow and slurred speech; no axillary hair; supine pulse rate 52 beats/minute, erect pulse rate 68 beats/minute; supine blood pressure 115/80 mm Hg, erect systolic blood pressure 75 mm Hg. A clinical diagnosis of hypopituitarism second-ary to postpartum infarction (Sheehan's Syn-drome) was made. After appropriate blood tests were taken she was given intravenous hydrocor-tisone 100 mg 6 hourly for 2 days, followed by prednisolone 5 mg mane and 2.5 mg nocte. Blood glucose levels normalised within 24 hours, and the patient's clinical condition improved dra-matically. She was started on L-thyroxine 100 J1g daily. She was discharged from hospital on the lOth day on the above doses of prednisolone and thyro~­ine. She was also given pyrimethamine 25 mg !J.ai1y. She was able to return to work a month after discharge and follow-up after 4 months showed her to be very well. Results of investigations prior to hydrocortisone were: semm cOI·tisol 36 nmol/I semm thyroxine 0.1 pmol/I semm TSH 0.32 mlV/1 semm FSH 4 IV/I serum LH 1.0 IV/I semm prolactin 2.0 mg/ml (normal 150 - 650 nmol/I) (normal 8.0 . 12.0 pmol/I) (normal 0.4 - 4.0 mlV/l) (normal 1 - 8 IV/I) (nol'mal 1 - 11 IV/I) (normal 2 . 15 mg/ml) These results confirmed a diagnosis of hypopi-tuitarism. A skull xray was normal with no enlarge-ment of the sella turcica; an abdominal ultrasound showed a normal pancreas and no evidence of calcified adrenal glands. Discussion This patient's presenting illness and subsequent course in hospital illustrate a number of important points. First, hypoglycaemia must be considered in any case of coma, and if blood glucose measure-ments are not available it is always worthwhile administering a bolus of 50% glucose. Second, once hypoglycaemia has been proven the differential diagnosis must be explored (TABLE 1). Reproduced  by Sabinet Gateway under licence granted by the Publisher ( dated 2012)Malawi Medical Journal, July 1m, Vol. 8, No. '2 TABLE 1 CAUSES OF HYPOGLYCAEMIA Factitious - Insulin or sulphonylureas Ethanol induced Drugs - e.g. salicylates Acute infections - malaria, septicaemia Severe liver disease Sarcoma, hepatoma, other malignant tumours Addison's disease, hypopituitarism Insulinoma In the patient there was no reason to suspect factitious, ethanol induced or drug induced causes of hypoglycaemia. There was no clinical evidence of septicaemia, severe liver dise~e or malignancy .. This left the possibility of Addison's disease, hy-popituitarism or an insulinoma. Hypoadrenalism was suspected by the initial low serum sodium on admission, and the marked postural hypotension despite normal hydration status. Hypoadrenalism is due either to disease of the adrenal glands or secondary to pituitary dysfunction. In this case, hypopituitarism was considered by the clinical fea-tures of gonadotrophin deficiency (failure of men-struation and loss of secondary sexual characteristics), prolactin deficiency (failure to breast feed following delivery) and hypothyroidism (puffy face, slow mentation and speech and. brady-cardia with an abnormal response to drop in blood pressure). Third, in considering the causes ofhypopituitar-ism (TABLE 2), the advent of clinical features of gonadotrophin and prolactin deficiency following pregnancy made post-partum infarction of the pi-tuitary gland the most likely possibility. '19 TABLE 2 CAUSES OF HYPOPITUITARISM Congenital Pituitary tumours Malignant diseaSe Infections Granulomatous disease Vascular disease Iatrogenic - tuberculosis; syphilis; encephalitis - sarcoidosis - "Sheehan's syndrome" During pregnancy the pituitary gland becomes hyperplastic, and is therefore susceptible to ischae-mia and infarction in the event of hypotension from postpartum haemorrhage, anaesthetic proce-dures etc. Sheehan's syndrome (as it is called) is thought to be the commonest cause of hypopitui-tarism in Mrica. Initially, there is failure of secre-tion of LH, FSH and prolactin, and this is followed by various degrees of hypothyroidism and/or adrenocortical insufficiency. These latter deficien-cies may only be unmasked by some stressful situ-ation such as infection and trauma, and this was presumably the case in our patient. Although the confirme~ diagnosis of hypopituitarism requires refined tests, it can be suspected by attention to the history and clinical examination. We were quite happy to make the diagnosis on the history and examination, and to institute treatment accordingly. As health workers in Mrica, we are continually confronted with scarce resources, and decisions have often to be prioritised. It is therefore of vital importance that treatable causes of illness are ident-ified. Hypoglycaemia is a treatable cause of coma, and hypoadrenalism/hypopituitarism are treatable causes of recurrent and protracted hypoglycaemia. Reproduced  by Sabinet Gateway under licence granted by the Publisher ( dated 2012)

Unusual cause of coma

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Unusual cause of coma

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