Endocrine Abstracts

33-year old obese but otherwise considered ’healthy’ patient was admitted to department of surgery due to wet gangrene of left foot. Lower leg amputation was done. As patient was obese with ITM 44 kg/m² endocrinologist was consulted. In overnight 1 mg dexamethason supression test cortisol was 72 nmol/l, HbA1c was 5.7%, TSH was 8 mIU/l, level of 25-OH D vitamin below lower range and arterial blod pressure was normal (130/80 mmHg). Patient had central obesity with muscle wasting and gynecomastia, but did not have any purple stirae, bruises, fat pads or hypertension. During stay worsening of clinical condition with respiratory insufficiency due to sepsis occured and patient was transfered to Critical care unit. Debridemenet and re-amputation were needed so few surgical procedures were done and dexmedetomidine for sedation was repeatedly given during few days. After stabilisation of clinical state polyuria was noticed and although patient was normotensive and sodium and potassium level as plasma osmolality were normal, level of cortisol was checked and found to be below level of detection (< 11 nmol/l). Level of pituitary hormones was normal: TSH 2,7 mIU/l, FSH 18,54 IU/l and slightly elevated LH 15,19 and prolactin 646 mIU/l together with ACTH 10,7 pmol/l. Level of peripheral thyroid hormons and testosteron was normal (FT4 12,44 pmol/l, testosterone 9,39 nmol/l) as were SHBG 57,1 nmol/l. CT radiography of adrenal glands showed no signs of necrosis or haemorrhage of the adrenals which morphology was normal. Short test with 250 ug Synacthen iv. was done and showed no adequate adrenal response, cortisol was 100 nmol/l after 30’ and 107 nmol/l 60’ after stimulation. After one week of supstitution with hydrocortison (20+10 mg per os daily) as surgical treatment was over and discharge was planned, afternoon dose of hydrocortisone was omitted and level of cortisol on 0800 h was 83 nmol/l. We concluded that partial recovery of adrenal gland happened but patient was recommended to continue with low dose hydrocortison supplementation (10+5 mg tbl). Control work –up in Outpatient clinic was scheduled. Aim of this case presentation is to remind of possible causes of adrenal failure, not only due to sepsis but also malnutrition, drugs – in this particular case dexmedetomidine and to recall other possible mechanisms of adrenal failure in severe or critically ill patients, even in those who might first seem to have Cushing syndrome as was the case with this patient.