Endocrine Abstracts

Background: Pericarditis as a presentation of sever adrenal insufficiency (AI) is very rarely documented. We would like to present a rarely case of sever AI whose first clinical presentation was pericarditis with heart failure and cardiac tamponade.

Case presentation: A 35 years old man was hospitalized on Department of Internal Medicine for chest pain, shortness of breath and hypotension. On ECG was documented sinus tachycardia with diffuse ST elevation. Cardio specific enzymes were negative, D-Dimers increased, serum hyponatremia and hyperkalemia. Urgent CT pulmonal angiography ruled out suspected pulmonary embolism and revealed pleural and pericardial effusion. Bedside echocardiography confirmed severe cardiac tamponade. Despite of urgent pericardiocentesis in emergency settings with a total amount of 1,000 ml, hypotension continued without adequate effect od high dose of vasopressors’ therapy. The prolonged shock status was based on unmeasured plasmatic concentration of cortisol: 20 nmol/l (185- 624). In addition, we found out that the patient was treated for congenital adrenal insufficiency (CAH) in childhood, unfortunately without compliance for treatment as an adult (12 years did not used glucocorticoids). On abdominal CT scan has been detected bilateral adrenal hyperplasia. In the next 6 months he was repeatedly hospitalized for relapsing pericardial effusion accompanied with shock as well as hepatic and renal failure. The definitive clinical stabilization was achieved after adequate substitution therapy (glucocortiocoids and fludrocortisone). Genetic test confirmed the deficiency of 21 – hydroxylase.

Conclusion: Pericarditis and cardiogenic shock, or prolonged hypotension without vasopressors effects can be sign of unknown adrenal insufficiency. Early diagnosis and urgent treatment with supplementation of glucocorticoids is important to avoid morbidity and mortality.