A 32-year-old woman comes to the office due to lightheadedness. She had an uncomplicated vaginal delivery 6 weeks ago with minimal blood loss. The patient had mild fatigue and backache during the last trimester of pregnancy, but the fatigue has worsened since the delivery. She has also been having intermittent generalized abdominal pain, loss of appetite, and weakness. She says her skin is tanning even though she has spent only minimal time outdoors. Yesterday, the patient felt like she was "going to pass out" and experienced several episodes of lightheadedness accompanied by nausea and abdominal discomfort. She has no chest pain, shortness of breath, or bleeding. The patient has a history of hypothyroidism and takes levothyroxine. Her temperature is 36.1 C (97 F), blood pressure is 110/60 mm Hg supine and 85/45 mm Hg standing, and pulse is 104/min. Skin shows generalized hyperpigmentation. Lungs are clear, and her heart rate is tachycardic but regular with no gallops or murmurs. Abdominal examination shows mild, diffuse tenderness without guarding and normal bowel sounds. Laboratory results are as follows:

Postpartum adrenal insufficiency (AI) may be due to adrenal (primary AI) or pituitary (secondary AI) disease. Hyperpigmentation and signs of mineralocorticoid deficiency suggest primary rather than secondary AI.

Ethosuximide is usually a very safe drug, but can cause significant sedation. Aplastic anemia but not hemolytic anemia (choice A) has rarely been associated with the use of ethosuximide, and with carbamazepine and felbamate.Hepatotoxicity (choice C) is a rare but potentially lethal adverse effect of valproic acid that occurs most commonly in children under the age of 2 and those taking multiple drugs. Authorities recommend monitoring liver function tests when starting this drug. Nephropathy (choice D) is not usually reported with antiseizure drugs. Torsade de pointe arrhythmia (choice E) has not occurred with significant frequency during use of anticonvulsant drugs.

41) Antiarrhythmic drugs have a variety of adverse effects that must be monitored carefully. Which of the following drugs is associated with discoloration of the skin, photosensitivity, thyroid dysfunction, and pulmonary complications?

Amiodarone is a large, insoluble molecule that deposits in skin (and the cornea) and causes photosensitivity. It contains two iodine atoms, which may be responsible for binding to thyroid receptors and the observed thyroid problems. It is associated with pulmonary fibrosis (sometimes fatal), but the mechanism is unknown. In spite of these adverse effects, it is extremely useful in arrhythmia treatment. Diltiazem (choice B) is associated with constipation and cardiac depression; ibutilide (choice C) with torsade de pointe arrhythmia, lidocaine (choice D) with convulsions, and procainamide (choice E) with torsade de pointe arrhythmia and drug-induced lupus.

Losartan, an AT1 angiotensin receptor antagonist, has been shown to slow the progression of heart failure, in common with the ACE inhibitors, beta blockers, and spironolactone, which also slow progression of this disease. Positive inotropic agents such as digoxin (choice A) and dobutamine (choice B) do not slow progression although they may be useful for reducing symptoms. Nesiritide (choice D) is a peptide that causes vasodilation and sodium diuresis and may have value in acute but not chronic failure. Propranolol (choice E) probably slows progression of heart failure but it has direct negative inotropic effects on the heart.

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