Lesson of the Week: The mineralocorticoid effects of high dose hydrocortisone

Case report

A 63 year old man with a history of alcohol abuse presented with a two day history of haematemesis, melaena, and blackouts. He admitted drinking 3.4 litres of beer a day but denied drinking in the week before admission because of indigestion. On examination he was pale with a generalised purpuric rash. The liver was enlarged to 5 cm below the costal margin, and he had a small retinal haemorrhage. A full blood count showed a haemoglobin concentration of 51 g/l, a white cell count of 8.8x10⁹/l, and a platelet count of 4x109/l. Electrolyte analysis showed the following plasma concentrations: sodium 131 mmol/l (normal 133-144 mmol/l), potassium 3.7 mmol/l (normal 3.4-5.2 mmol/l), total calcium 1.92 mmol/l (normal 2.26-2.60 mmol/l), urea 9 mmol/l (normal 2.5-7.5 mmol/l), and creatinine 91 μmol/l (normal 50-100 μmol/l). A coagulation screen gave a thrombin time of 12.5 s (control 13.0 s), a prothrombin time of 14.2 s (control 13.7 s), a kaolin cephalin clotting time of 39.3 s (control 40.8 s), and a reduced thrombotest result of 60%. (The thrombotest is a combined assay of the activities of factors II, VII, IX, and X.) Liver function tests showed the following serum bilirubin concentrations: 11 μmol/l (normal 1-17 μmol/l), albumin 24g/l (normal 35-50 g/l), and (gamma)-glutamyltrans-ferase 60 IU/l (normal <45 IU/l).

An electrocardiogram showed a short PR interval of 0.08 s (figure 1). Heart size appeared normal on chest radiography, but there …