Back in the ICU, Glick followed the patient closely. Hours passed, then days, and although his blood pressure was better, it remained too low. Why? Glick sent test tube after test tube to the lab, looking for signs of infection, inflammation, autoimmune diseases — anything she could think of. After the man’s near-death experience, Glick knew many of his lab results would be abnormal. His liver was damaged, his kidneys, his heart. It was her job to determine which abnormalities were the result of his rapid decline and which were the cause.
Anomalous results poured in, but only one surprised the resident. The man’s thyroid gland was not making his essential hormone. The thyroid is like the carburetor in an old combustion engine. It tells the body when to speed up and when to slow down. At this time, the man’s body had to be fully boosted, but without this hormone it would not be possible. Before giving the man replacement hormones, Savarimuthu reminded Glick that they should check his cortisol levels again. They had it checked when he arrived, and it was high — as expected, given the physiological stress he was under. But administering thyroid hormone to someone with a cortisol deficiency is like starting a car with no oil in the engine. You could ruin the whole machine. So Glick sent a second cortisol level test. This time the level was undetectable. She checked again: undetectable.
The steroid test
Another test revealed the cause: His adrenal glands, where cortisol is made, were not working at all, as was his thyroid. She started the man on steroids — an artificial form of cortisol — along with thyroid hormone and consulted the endocrine team. She then looked at Westerly’s records, where she saw deep into his map that he had been given steroids there. Because he was not deficient when he arrived, and they hadn’t listed the steroids in their notes, Glick hadn’t administered them at Yale New Haven. She now turned to the medical literature to find out what could have caused these devastating twin hormone deficiencies.
It wasn’t long before it was determined that he must have autoimmune polyglandular syndrome type 2. In this rare condition, the immune system suddenly and accidentally begins to attack parts of the patient’s own body – in this case, the thyroid and adrenal glands. Why this happens is not well understood. A few hours after receiving both replacement hormones, the young man was healthy enough to wean off the drugs that kept his blood pressure levels up. A few days later he was healthy enough to leave the ICU. Ten days later he was able to go home.
Once the patient understood what he had and started to feel the benefit of the treatment, he realized that he had been sick long before that coin went wrong. He will have to take these hormones for the rest of his life, but he feels better than in years. No one knows exactly when his glands were destroyed; it was probably a long time ago. “I’m not one to go to the doctor,” he admitted. He thought he was just getting old: “You know what they say – after 30 it all goes downhill.” But not anymore. Not for him anyway.
Lisa Sanders, MD, is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to talk to Dr. Sanders, write to her at [email protected]