Der Internist
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Review Case Reports
[Adrenal crisis. Diagnostic and therapeutic management of acute adrenal cortex insufficiency].
Acute adrenal insufficiency is a rare but life-threatening disorder that develops as a result of inadequate adrenal steroid production. Early diagnosis is key for effective and life-saving treatment of the affected patients. ⋯ Adrenal crisis in patients with known chronic adrenal insufficiency is nowadays rare, but can only be prevented by structured patient education on stress-related glucocorticoid dose adjustment. Outcome of adrenal crisis is crucially determined by the physician's clinical competence and immediate initiation of specific treatment.
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This review describes the current guidelines of German diabetes association for the management of diabetic coma, both of diabetic ketoacidosis and hyperosmolal coma. The outline focuses on emergency treatment and the management on the intensive care unit, in particular, volume and insulin therapy, and potassium replacement. ⋯ Also, the indications for bicarbonate therapy in diabetic ketoacidosis are critically discussed, as well as phosphate and magnesium replacement. With today's therapeutic possibilities the therapeutic goal, i.e. a low mortality, may be achieved, dependent on the underlying illness.
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Severe hypercalcemia is a life-threatening medical emergency. It is most commonly caused by malignant tumors, but can also be caused by primary hyperparathyroidism or less often by a dysregulated production of active vitamin D in granulomatous disorders. Symptoms include nausea, vomiting, renal insufficiency, severe dehydration, lethargy, confusion, and even coma. ⋯ Calcitonin and intravenous infusion of bisphosphonates reduce serum calcium levels by interfering with calcium release from the skeleton. Dialysis with a low or zero calcium dialysate is reserved for patients who are refractory to these measures. Corticosteroids are effective with hypercalcemia due to increased vitamin D levels and in multiple myeloma.
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Pulmonary-renal syndrome is a potentially life-threatening disorder, characterised by diffuse alveolar hemorrhage on the basis of pulmonary capillaritis in association with rapidly progressive glomerulonephritis. It can originate from various systemic autoimmune diseases. ANCA-associated vasculitides account for approximately 60% and Goodpasture's syndrome for approximately 20% of the cases. ⋯ By accelerating the diagnosis of the specific underlying disease, auto-antibody testing fosters rapid initiation of treatment and thereby strongly improves the prognosis of pulmonary-renal syndrome. Intense immunosuppression with cyclophosphamide and glucocorticoids, augmented by plasmapheresis in the event of Goodpastures's syndrome, is the mainstay of therapy. Supportive measures such as temporary ventilation and hemodialysis have further reduced mortality.