Case 3: Emesis and Oral Hyperpigmentation in a 17-year-old Girl.

Abstract

1. Meghan E. Fredette, MD* 2. Lisa Swartz Topor, MD, MMSc* 1. *Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI A 17-year-old girl presents for evaluation of persistent emesis and an unintentional 13.2-lb (6-kg) weight loss during the past 3 months. Emesis occurs daily in the mornings and is nonbloody and nonbilious. Nausea improves throughout the day and with hot showers. She denies diarrhea. When eating, she prefers salty foods such as pickles. She reports daily marijuana use. She feels that marijuana has stained her lips and tongue, as they appear darker to her. She notes fatigue, epigastric pain, weakness, and dizziness. She denies fevers, dysuria, or headaches. On physical examination she is afebrile, with a heart rate of 140 beats/min, respiratory rate of 18 breaths/min, blood pressure of 86/52 mm Hg, and oxygen saturation of 98%. Her weight is 91 lb (41.3 kg) (<1st percentile), height is 59 in (150 cm) (2nd percentile), and body mass index is 18.3 (14th percentile). Patchy hyperpigmentation is noted on the lips, buccal mucosa, and palate. Bowel sounds are hyperactive, and abdominal examination is without tenderness, rebound, or guarding. There are no masses or hepatosplenomegaly. Laboratory evaluation reveals a low serum sodium level of 130 mEq/L (130 mmol/L), with a normal potassium level of 3.8 mEq/L (3.8 mmol/L). Urine pregnancy test result is negative. The results of thyroid function testing, liver enzymes, lipase, complete blood cell count, and inflammatory markers are within normal limits. Abdominal radiograph is normal. Additional laboratory testing reveals the diagnosis. Random serum cortisol and corticotropin samples were sent in the setting of hypotension and tachycardia, and a stress dose of …