1 Comparison of 68Ga-DOTATOC-PET/CT and PET/MRI hybrid systems in patients with cranial meningioma: Initial results Neuro-Oncology, July 24, 2014
2 Comparison of the accuracy of PET/CT and PET/MRI spatial registration of multiple metastatic lesions American Journal of Roentgenology, November 22, 2013
3 Identifying decreased peristalsis of abnormal small bowel segments in Crohn's disease using cine MR enterography Abdominal Imaging , November 10, 2014
4 Evaluation of the PET component of simultaneous [18F]choline PET/MRI in prostate cancer: comparison with [18F]choline PET/CT European Journal of Nuclear Medicine & Molecular Imaging, October 4, 2013
5 18F-FDG-PET/CT is of limited value in primary staging of early stage cervical cancer Abdominal Imaging , January 5, 2015
Question: Recall that a 43-year-old female was brought to the ED for evaluation of acute mental status changes. On examination, she appeared to be a healthy woman in her 40s. She had global disorientation and cognitive blunting, and responded inappropriately to simple questions. She was non-combative.
Vulvar, blood, urine, and CSF cultures were obtained, and the patient was transferred to the ICU.
Radiographic studies indicated extensive necrotizing fasciitis extending from the left labium into the left flank. Broad-spectrum antibiotic therapy was begun and wide debridement of the groin and left flank was done. Frozen section biopsy at the time of surgery met the diagnostic criteria for necrotizing fasciitis.
The blood cultures revealed Escherichia coli, Proteus mirabilis, and mixed anaerobic bacteremia. The CSF and urine cultures were negative. She received inotropic support, daily sharp wound debridement in the operating room, continued broad-spectrum antibiotic therapy, insulin therapy for severe hyperglycemia (>500 mg/dL) and twice daily hyperbaric oxygen therapy. Despite recovery from the acute sepsis episode, the mental status changes persisted with paranoid delusions.
Testing showed that serial urine free cortisol levels were elevated (8518-9703 μg/24 h). Plasma cortisol levels were markedly elevated at 138 μg/dL and 127 μg/dL in the morning and evening, respectively. An ACTH level was well above the normal range at 317 pg/mL. The cortisol response to a CRH stimulation test was flat and elevated (137 μg/dL at baseline and 182 μg/dL after stimulation). There was suppression of urine free cortisol or 17-hydroxysteroids after high-dose dexamethasone suppression testing. A CT of the adrenal glands revealed massive bilateral adrenal hyperplasia.
What would you do now?
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