Differential Diagnosis
- Single most likely diagnosis
- Adrenal insufficiency: The patient's low cortisol level (am cortisol 11.8) and high ACTH (42) suggest primary adrenal insufficiency. The low aldosterone and renin levels also support this diagnosis, as adrenal insufficiency can lead to decreased production of these hormones.
- Other Likely diagnoses
- Pheochromocytoma: Although the metanephrines and normetanephrines are elevated, the patient's hypotension and low epinephrine level make this diagnosis less likely. However, it is still possible, especially given the elevated norepinephrine level.
- Congenital adrenal hyperplasia (CAH): The patient's elevated testosterone level could suggest CAH, but this is less likely given her post-menopausal status and lack of other symptoms.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Adrenal crisis: Although the patient's cortisol level is low, she may still be at risk for adrenal crisis, especially if she is not treated promptly.
- Pheochromocytoma crisis: If the patient does have a pheochromocytoma, she may be at risk for a crisis, which could be life-threatening.
- Rare diagnoses
- Familial glucocorticoid deficiency: This is a rare genetic disorder that affects the production of cortisol, but it is typically diagnosed in childhood.
- Allgrove syndrome: This is a rare genetic disorder that affects the production of cortisol, aldosterone, and other hormones, but it is typically diagnosed in childhood.
- Hypothalamic-pituitary-adrenal axis dysfunction: This could be a rare cause of the patient's low cortisol level, but it would typically be associated with other symptoms, such as hypogonadism or growth hormone deficiency.