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Table 1

During the next 10 days, the vomiting continued, and intermittent fever, epigastric pain, nasal congestion, and cough developed. When the episodes of vomiting increased in frequency, the patient’s parents took her back to the emergency department of the other hospital. The blood pressure was 162/112 mm Hg and the heart rate 98 beats per minute. The patient reported nausea; mild tenderness was noted in the left upper quadrant of the abdomen. The blood level of potassium was 2.7 mmol per liter (reference range, 3.5 to 5.1). Tests for severe acute respiratory syndrome coronavirus 2, influenza A and B viruses, and respiratory syncytial virus were negative. Other laboratory test results are shown in Table 1. Intravenous ondansetron, fluids, and potassium were administered, and the patient was transferred to this hospital for further treatment.

On arrival at this hospital, the patient reported a 3-month history of intermittent headaches and dizziness that had progressively increased in frequency from once or twice weekly to daily. For years, she had had intermittent chest pain, palpitations, and tremors that were associated with anxiety. These symptoms had increased in severity and frequency in the 10 days before the current admission. The patient had had a decreased appetite that was associated with depression, with an unintentional weight loss of 7 kg in the year before this admission. She reported no diarrhea, constipation, joint pain, or cold or heat intolerance. There was no acne or hair loss, but the patient described excessive hair growth on the back. She had no rash, but she described skin-colored stretch marks under the breasts and on the buttocks. The menstrual cycles were regular; she was currently menstruating.

The patient’s depression had led to a suicide attempt and psychiatric hospitalization 5 months before the current admission. She took no medications, had no known allergies, and had received all routine childhood vaccinations. The patient’s weight had been in the 50th percentile at 8 years of age, had increased to the 75th percentile by 12 years of age, and then had decreased to the 50th percentile at 13 to 14 years of age. The patient was in high school and lived in a suburban area of New England with her parents, two siblings, and several members of her extended family. She reported that she was not sexually active. She vaped flavored nicotine but did not smoke cigarettes, drink alcohol, or take illicit drugs. Her parents and siblings were healthy.

On examination, the temporal temperature was 36.9°C, the blood pressure 180/116 mm Hg, the heart rate 103 beats per minute, and the respiratory rate 20 breaths per minute. The patient appeared healthy and comfortable, and she was alert, awake, oriented, and cooperative. The neck was supple; a bruit was noted over the left carotid artery. Examination of the heart and lungs showed no abnormalities. The abdomen was nondistended, nontender, and soft, without organomegaly or masses. No acne or excessive hair was present on the face. No rash was noted on exposed skin, and there was no pain or swelling in the joints. The legs were warm, without swelling. The blood level of potassium was 2.9 mmol per liter (reference range, 3.4 to 5.0), the white-cell count 7650 per microliter (reference range, 4500 to 13,500), and the erythrocyte sedimentation rate 98 mm per hour (reference range, 0 to 19). Other laboratory test results are shown in Table 1. Intravenous hydralazine and oral potassium chloride were administered, and treatment with amiloride was started.