Hypercalcaemia is a rare, albeit well-described feature of hypoadrenalism, although the mechanism underlying this is remains controversial. Primary adrenal failure is known to occur secondary to infective agents, and indeed tuberculous infiltration of adrenal tissue represents one of the leading aetiologies worldwide. Primary adrenal failure has also been shown to occur secondary to sepsis with Meningococcus or Pseudomonas species, but classically this presents with an acute adrenal failure in the Waterhouse-Friderichsen syndrome.
We present the case of a 48-year-old woman who presented in July 2010 with a severe legionella pneumonia and septicaemia necessitating ventilatory and circulatory support in the Intensive Care Unit. Her illness was complicated by peripheral ischaemia, which led to her having bilateral below knee, multiple right finger, and left hand amputations. She made a steady systemic recovery, but two months following her admission was noted to have a persistently raised serum corrected calcium level. Investigation of this excluded common aetiologies, and she went on to have a short Synacthen test, which showed a baseline cortisol of 146 nmol/l, and a 30 min cortisol level of 357 nmol/l, consistent with a diagnosis of hypoadrenalism. The patient was started on hydrocortisone replacement, and within a few days her calcium level had returned to normal.
Primary adrenal failure has been shown to occur acutely during septic episodes, however we have found no reports of this occurring following Legionella sepsis. This case is interesting both in terms of the rare presentation with hypercalcaemia, because of the duration between the septicaemia and the development of hypoadrenalism, and because of the association of this with an unusual organism.