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A 42-year-old woman is brought to the emergency department 30 minutes after her husband found her unconscious in her bed. She has a 6-year history of systemic lupus erythematosus treated with prednisone. Her husband says she has been on a drinking binge for the past 7 days and has not been eating. Three days ago, she had the onset of rhinitis, conjunctivitis, and a nonproductive cough. She has a long-standing history of alcoholism. She moans in response to painful stimuli. Her temperature is 38.9°C (102°F), pulse is 110/min, respirations are 22/min, and palpable systolic blood pressure is 80 mm Hg. The lungs are clear to auscultation and percussion. Abdominal examination shows no abnormalities. Fluid resuscitation is begun. Which of the following is the most appropriate initial step in management?
a) Serum antinuclear antibody assay
b) Corticosteroid therapy
c) Ganciclovir therapy
d) Nonsteroidal anti-inflammatory drug therapy
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i cant understand the concept of using corticosteroid?? pls explain
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She has adrenal insufficiency
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This is one of those questions that is intentionally vague and can leave you feeling confused. When they give you very little information, then you can be sure there will be some kind of logical flow they want you to use to rule things out and choose the most likely diagnosis even if it can't be clinched with certainty.
Adrenal insufficiency is unlikely due to her high fever. If they don't give you an electrolyte panel (to show you low sodium or high potassium) and expect you to make a diagnosis of adrenal insufficiency, they would not give you atypical symptoms like a high fever (AI should have lowered body temp). Treating AI is indeed with corticosteroids, but if you treated AI in this case you were lucky that the answer happened to match the treatment of the issue they were trying to point you toward 
Given the vague systemic symptoms and the point blank information that she has a history of Lupus, it is much more likely that she is having a Lupus flare in this case. Her low blood pressure is due to cardiac tamponade, one of the most dire (and thus tested!) complications of severe lupus.
Remember RASH RN for lupus: Rash, Arthritis, Serositis (tamponade, pleural pain), Hemolysis, Renal injury, Neurologic symptoms (psychosis, seizure, stroke)
Treatment is bolus of steroids.
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Nevermind I'm dumb. Wish this let you delete posts. Here is a better explanation from someone else:
Yes, it is B, acute adrenal crisis from secondary adrenal insufficiency due to chronic prednisone use.
Secondary adrenocortical insufficiency occurs when exogenous steroids have suppressed the hypothalamic-pituitary-adrenal (HPA) axis. Too rapid withdrawal of exogenous steroid may precipitate adrenal crisis, or sudden stress may induce cortisol requirements in excess of the adrenal glands' ability to respond immediately. In acute illness, a normal cortisol level may actually reflect adrenal insufficiency because the cortisol level should be quite elevated.
symptoms of adrenal crisis: tachycardia, hypotension, hypoglycemia. Treat with corticosteroid.
[Primary adrenocortical insufficiency occurs when the adrenal glands fail to release adequate amounts of these hormones to meet physiologic needs, despite release of ACTH from the pituitary. Infiltrative or autoimmune disorders are the most common cause, but adrenal exhaustion from severe chronic illness also may occur.]
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Don't worry doc, better to be over-prepared than under-prepared.
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Just to be sure I didn't mess anyone up, adrenal insufficiency DOES present with fever. Don't know where I got low body temp from..also there is not a single other symptom of lupus present here unless you possibly count the neurologic symptoms which can present in both. You can't necessarily exclude Lupus flare but AI is the best answer based on the information given, and fortunately they have the same treatment (Steroid bolus).
Both acute and chronic renal insufficiency --> weakness, fatigue, confusion, nausea, vomiting, anorexia, hypotension, hyponatremia, hypokalemia, hypoglycemia, metabolic acidosis
Acute adrenal insufficiency --> profound hypotension, fever, confusion, coma
Look for withdrawal of steroids as in this case (and watch for distractors that simply serve as a reason for the patient to be on steroids like SLE!!)
Chronic adrenal insufficiency --> hyperpigmentation (must be long-standing)
chronic is usually autoimmune (Addison's), one of my profs always said think of JFK because he had Addison's and people always think of him as being fit and tan..idk it stuck with me hah
[Note: Most review books/profs would say think of the electrolyte abnormalities in adrenal insufficiency as the opposite of Cushings and hyperaldosteronism since it helps you keep these disorders together.
Cushings and Primary Hyperaldosteronism--> Aldosterone Saves Sodium and Pushes out Potassium and H+ (causing metabolic alkalosis). Just think in your head that Na is (+) charged so in order to hold on to it, Aldosterone trades H+ and K+ for Na+ to keep the charges balanced.
Adrenal insufficiency--> just the opposite due to low aldosterone: Low Na, High K, High H (metabolic acidosis)]
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Thanks mastarhiz, mostly for doin the lawd's work on here. Have read many good explanations from you!
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