Internal medicine and rheumatology specialist Siobhan Deshauer, MD, solves the mystery case of Sarah, a woman who began experiencing unusual dietary cravings and other symptoms.
Following is a partial transcript of the video (note that errors are possible):
Deshauer: Meet Sarah, a 33-year-old woman who noticed an unusual change in her eating habits. Her cravings for salty snacks had gotten out of control. What started as an occasional indulgence had turned into an obsession and she found herself finishing an entire jar of pickles each day. That's a lot of pickles. But this was more than just a craving. Little did she know that this was actually the first sign of a serious medical condition that would change the rest of her life.
For the past few months, Sarah hadn't felt like herself. She was tired and these salt cravings had become so intense. Each time she walked by the kitchen, she would reach for the pickle jar, open a bag of chips, or grab some popcorn. At meal times, she was practically coating her food in extra salt. At the same time, she just couldn't quench her thirst.
Sarah had never been big on drinking water. In the past, she had actually needed to use a water-tracking app to make sure she was getting enough. But these days she had an unquenchable thirst and she was guzzling back liters of water per day. Then the nausea, annoying stomach pain, started. She tried taking antacids and changing her diet, but nothing seemed to help. So she told one of her friends about it who thought it sounded like she was pregnant. Fatigue, nausea, and weird cravings -- maybe they were right. Sarah took three different pregnancy tests, but they were all negative.
Next, she noticed she was losing weight without even trying. Then one morning she woke up with a cough and her whole body was aching. She figured it was just just a cold. But when she stood up, she became really light-headed with spots filling her vision, warning her that she was about to pass out. Things went from bad to worse that day and it wasn't long before Sarah couldn't even go from lying down to sitting up without becoming extremely dizzy. That's when Sarah knew that she had to go to the hospital.
In the emergency department, the nurse took her blood pressure while she was lying down, which was 90/50. She always had low blood pressure, but this was lower than usual. Then the nurse asked her to sit up in bed, and just like before, Sarah started feeling dizzy again. Her blood pressure dropped to 80/40. She also had a fever and an elevated heart rate. Although she was breathing a little bit faster and she had a productive cough, her oxygen levels were still normal.
The emergency doctor ordered a chest x-ray and some blood work to investigate. Looking at the chest x-ray, you can see here that there is an obvious pneumonia, and that explains the fever and cough. Then her blood work returned showing multiple abnormalities. Her white blood cell counts were elevated, which is consistent with pneumonia, but concerningly her creatinine was elevated, suggesting a kidney injury. Plus, her potassium was a bit high at 5.1 -- not in the danger zone yet, but if potassium gets too high, it can cause your heart to stop. Despite all the salty food she was eating, her sodium levels were actually low. The emergency doctor gave Sarah a diagnosis of sepsis secondary to pneumonia.
Sepsis is a life-threatening condition where the immune system overreacts to an infection leading to inflammation and organ damage. The key is early recognition and treatment, so Sarah was immediately started on broad spectrum antibiotics and IV fluids before being admitted to hospital for observation. Pretty straightforward, right? But this isn't your typical case of sepsis, as we'll soon find out.
The next morning the internal medicine specialist reviewed Sarah's chart and looked at her morning blood work. Her kidney function had returned to normal. Good, and just as I'd expect after getting rehydrated with IV fluids. But what was unusual is that her sodium was still a bit low, her potassium was still a bit high, and her blood pressure was persistently low. That's not what I would expect from a typical pneumonia. And when your patient isn't responding to treatments the way you'd expect, that's the moment to step back, look at things again, and make sure that you have the right diagnosis.
Now, there are many causes of low sodium that we need to consider, and similarly there is a long list of conditions that cause low blood pressure. Then it's picking out which conditions overlap and can cause both symptoms, sort of like a matching game. With these potential causes in mind, the internal medicine physician went to assess Sarah and this is what she found.
First, she noticed that Sarah was quite tanned, even though it was the fall and she didn't spend time in the sun or use tanning beds. Next, she asked Sarah to stick out her tongue and saw this: distinct brown markings on the bottom of her tongue. That's hyperpigmentation and it's a major clue for what's going on. The pieces of the puzzle are connecting. Salt cravings, abdominal pain, low blood pressure, electrolyte abnormalities, and now hyperpigmentation. This is an adrenal crisis. Sarah's adrenal glands aren't working properly. They are not making the hormones they are supposed to, which can be life-threatening, and it's all because she has Addison's disease, also known as primary adrenal insufficiency.
One thing I find so exciting about this case is that looking at the tongue was crucial for making a timely diagnosis. Your tongue can tell you a surprising amount about your health and I actually made a whole video talking about specific things to watch out for.
Now, to understand how an adrenal crisis caused Sarah's symptoms, we need to take a deep dive into the adrenal glands. These amazing organs sit on top of the kidneys like little hats and each layer is responsible for creating a different hormone that's essential for keeping you alive.
Think of it like a layered cake with different flavors. The outer layer makes aldosterone, a hormone that regulates sodium and potassium in the kidney. In simple terms, aldosterone makes the kidney retain sodium in your body and pee out potassium. In Sarah's case, without aldosterone, salt was flowing out of her through her urine and extra water was going with it. That's why she was experiencing the salt cravings and why she became so dehydrated with unquenchable thirst, dizziness, and low blood pressure.
The next layer of the adrenal gland makes cortisol. A lack of cortisol caused Sarah's nausea, abdominal pain, weight loss, and hyperpigmentation. Most often this happens in areas of friction like the way your teeth run along the bottom of your tongue. The next layer is DHEA, which is a precursor for testosterone and estrogen. Missing this one isn't life-threatening, but it can affect your mood, energy, and bone density. Last, but definitely not least, the innermost part of the adrenal gland makes stress hormones like epinephrine, which people commonly call adrenaline or the fight-or-flight hormone.
A fun fact, the inner core of the adrenal gland is actually quite distinct. I won't get into embryology, but it's a totally different type of tissue, even though we lump it in with the rest of the adrenal gland. As a result, it usually remains functional in Addison's disease, even when the rest of the adrenal gland is failing.
Watch the video above for more.
Siobhan Deshauer, MD, is an internal medicine and rheumatology specialist in Toronto. Before medicine, she was a violinist, which is why her YouTube channel is called Violin MD.