Endocrine Abstracts

A 69 year old man presented to the hospital after he fell from a 6 foot ladder. He was previously fit and well with no co-morbidities apart from a 55 pack year smoking history. He complained of right shoulder and hip pain. CT scan revealed fractures of the left 6th rib and right superior and inferior pubic rami. In addition, there was an incidental finding of a 5.2 cm in diameter abdominal aortic aneurysm (AAA) with no radiological evidence of a leak. He was treated conservatively on an orthopaedic ward. Two weeks later he developed signs of sepsis with pyrexia, hypoxia and oliguria and went on to develop multi-organ failure and was transferred to the intensive care unit (ICU). Emergency CT scan of the abdomen showed acute bilateral adrenal haemorrhage with stable and non-bleeding AAA. Upon endocrinology consult, he was commenced on intravenous hydrocortisone. A noticeable improvement was noted on day two of ICU stay following antibiotic, glucocorticoid therapy and inotropic support. Three sets of blood cultures showed no growth after 72 hours of incubation. On day three, he was transferred back to a base ward and was subsequently discharged home on oral hydrocortisone and fludrocortisone.

When reviewed in the endocrinology clinic he reported that he had not had any hydrocortisone or fludrocortisone tablets for 6 weeks as he did not realise he had to continue taking these medications. His short Synacthen test showed a basal serum cortisol level of 231 nmol/l and peak cortisol of 283 nmol/L and baseline ACTH level of 339 ng/l (0–46). His renin level was normal. He was restarted on hydrocortisone. He subsequently underwent endovascular AAA repair in November 2015.

Acute adrenal insufficiency resulting from extensive bilateral adrenal hemorrhage caused by sepsis is uniformly fatal if unrecognized and untreated.