Shouldering the Diagnostic Burden: Secondary Adrenal Insufficiency in a patient with steroid joint injections

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 1-16-Adrenal Insufficiency
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-16
Candice Rose*, Stewart Babbott and Rudruidee Karnchanasorn
The University of Kansas Medical Center, Kansas City, KS
Introduction: The prevalence of well-documented adrenal insufficiency (AI) is 5 in 10,000 in the general population. Hypothalamic-pituitary origin of disease is most frequent, with a prevalence of 3 in 10,000.  AI arising from suppression of the HPA axis as a consequence of exogenous corticosteroid (CS) treatment occurs in 0.5–2% of the population in developed countries.  Chronic AI manifests with relatively nonspecific signs and symptoms such as fatigue and loss of energy, often resulting in delayed or missed diagnoses. 

Clinical case: A 68-year old man with a history of osteoarthritis and HTN presented to the hospital with dizziness, fatigue, and orthostasis.  His anti-hypertensives were held and he was given IV fluids and discharged. Three weeks later, he was admitted for hypotension.  At that time we learned that he had received several injections with CS for joint pain 4 months prior. Because of persistent hypotension a serum cortisol was drawn and shown to be 3.6 mcg/dl (n 5-20) at midnight.  Standard cosyntropin stimulation test was performed at 8:00 am revealing a baseline cortisol level of 1.5 mcg/dl (n 7-22) and ACTH of <5 pg/ml (n 10-60).  Thirty minute cortisol level was 11.4 mcg/dl and 60 minute value was 19.6 mcg/dl.  Serum albumin was 3.5 g/dl (n 3.5-5).  Laboratory values of other pituitary hormones were obtained and were normal except for mildly low testosterone in light of normal FSH and LH. Brain MRI revealed no pituitary abnormality.  He was diagnosed with secondary AI and started on hydrocortisone 20 mg with breakfast and 10 mg in the afternoon.  His symptoms resolved with initiation of hydrocortisone.

Clinical lessons: A history of CS injections is often missed, as patients don’t consider it a current medication or don’t realize its significance. Taking a thorough history and asking about steroid injections is important. Secondary AI is often diagnosed later than primary AI since patients are less likely to have hypotension because of intact angiotensin-renin-aldosterone system.   Glucocorticoids have a role in maintaining peripheral vascular adrenergic tone, so loss of ACTH secretion can lead to hypotension.  AI should be considered in any patient with orthostatic hypotension.  Failure to recognize this condition can be life threatening. High-dose cosyntropin stimulation test can have misleading results in early-onset secondary AI because the adrenal glands still function and respond appropriately to cosyntropin.

Nothing to Disclose: CR, SB, RK

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