Endocrine Abstracts

Introduction: Acute adrenal insufficiency (AAI) is a rare but life-threatening condition. It may occur in 50 to 60% of septic shocks (SS). Its diagnosis can be difficult as symptoms are sometimes nonspecific. Herein, we report the case of a female patient with an AAI revealed during SS. A 30-year-old woman with a history of celiac disease since the age of 25 on a gluten-free diet, presented to the emergency department with abdominal pain, vomiting, fever and profound asthenia evolving for five days. Physical examination revealed an increased pulse rate of 120 beats per minute, a rapid respiratory frequency of 40 cycles per minute, fever (38.8) and low arterial hypotension of 60/40 mmHg. The abdomen was diffusely painful. Blood investigations showed leukocytosis (14000), mildly increased C-reactive protein (CRP) (84 mg/l), hypoglycemia (0.5 g/l), severe hyperkalemia (7.22 mmol/l) and hyponatremia (122 mmol/l). Arterial blood gas test noted a metabolic acidosis. A Computed Tomography (CT) scan of the lungs, abdomen and pelvis was normal. The urine culture was positive. The diagnosis of septic shock due to urinary tract infection was then initially retained. The patient was treated with vasoactive drugs and appropriate antibiotic therapy. The evolution was marked by the persistence of abdominal pain, arterial hypotension, hypoglycemia and hydro electrolytic disorders. The diagnosis of acute adrenal insufficiency was therefore suspected and then confirmed by a low serum cortisol level of 1.6 μg/dl (6.–18). The patient received intravenous hydrocortisone hemisuccinate and parenteral rehydration.Clinical and biological improvement was noticed in few days.

Conclusion: Our case illustrates the difficulty of the diagnosis of an AAI during SS. Thus, acute adrenal insufficiency must be suspected in the context of SS especially in patients with hyperpigmentation; hyponatremia and/or hyperkalemia, a medical history of autoimmune disease or an increased vasopressor dependency. Parenteral rehydration and intravenous hydrocortisone hemisuccinate should be initiated immediately, even before laboratory confirmation of the diagnosis.