Endocrine Abstracts

Introduction: Glucocorticoids are widely used for their anti-inflammatory and immunosuppressive properties. Prolonged administration of synthetic glucocorticoids is one of the most common cause of ACTH deficiency and consequent adrenal insufficiency. Exogenous glucocorticoids interfere with and suppress HPA axis and abrupt steroid withdrawal leaves body susceptible to adrenal insufficiency. Symptoms can range from adrenal crisis to nonspecific complains of fatigue, nausea and unexplained fever. Moreover, clinical picture of adrenal insufficiency can be obscured by patient’s concomitant conditions. Timely diagnosis and treatment is essential for patients with adrenal insufficiency.

Case Report: We present a case of 45 year old female, who presented to the ER with nausea, vomiting, increasing fatigue and dysuria. On further examination, patient was found to be hypotensive and had fever. Patient’s medical history was significant for motor vehicle trauma that left her paraplegic and type 2 diabetes mellitus controlled with metfromin. Diagnosis of complicated UTI was made by clinical and laboratory findings and appropriate antibiotic therapy was started. Patients condition slightly improved but she remained hypotensive and febrile. Endocrine consultation for diabetes mellitus, revealed that patient started taking dexamethasone for Covid-19 infection that improved her energy and continued to take it irregularly for 6 months without proper medical supervision. Two weeks before presentation to the ER, patient abruptly stopped taking dexamethasone. Diagnosis of adrenal insufficiency secondary to steroid withdrawal was suspected, IV hydrocortisone was started empirically with close monitoring. Patient’s condition began to improve, she became afebrile and more active, her blood pressure and electrolytes stabilized. After a week, patient was discharged home with detailed plan of steroid tapering and frequent follow-ups.

Conclusion: Steroid withdrawal and adrenal insufficiency is rare and under diagnosed condition. Diagnosis of this condition remains a challenge for clinicians, as, patients may present to the ER with vague, nonspecific symptoms. While hypotension, gastrointestinal symptoms and electrolyte abnormalities are common presenting manifestations, fever as an additional possible sign of adrenal insufficiency should be kept in mind. Considering that clinical picture of adrenal insufficiency can vary greatly, it is important to take detailed medical history and to keep a high level of suspicion. Adrenal insufficiency can be life-threatening; therefore, it is crucial to diagnose and treat this disorder in time. When adrenal crisis is suspected, treatment should not be postponed for detailed diagnostic workup. Proper patient education and close monitoring of steroid tapering cannot be understated.

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509117/?fbclid=IwAR2o_PqMlyaoTMSNJltd44ZyeNKR3VYj49KpTcisVZndtMi8nyWvUF65BQ4#b4-kjfm-18-0181.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072923/?fbclid=IwAR1r8gbK67GzedySkBq-QEBz76_nIhzok36ZXF0JcYEgmjt3XIlS_Ju5HwA.

https://academic.oup.com/jcem/article/100/6/2171/2829580?fbclid=IwAR3C3NSjzMBs760o-9slPAJDgn4h4sChjehMJq8RJBuf0kMIjW9pSz7Wrw4&login=false.

https://www.jpsmjournal.com/article/S0885-3924(06)00718-4/fulltext?fbclid=IwAR1GRyNfBXHdeLbCaMLDOE9a0z_Edbo2j0KB3hmVL6TQLlKUAjmIodu9w4.