Searchable abstracts of presentations at key conferences in endocrinology
Endocrine Abstracts (2011) 26 P638

ECE2011 Poster Presentations Clinical case reports (73 abstracts)

Hyponatremic coma with seizures as onset of isolated ACTH deficiency

R A Trifanescu 1, , A Stoicescu 3 , A Caragheorgheopol 2 , D Hortopan 2 & Mihail Coculescu 1,


1‘Carol Davila’ University of Medicine and Pharmacy, Bucharest, Romania; 2‘C.I. Parhon’ Institute of Endocrinology, Bucharest, Romania; 3‘Transilvania’ University, Brasov, Romania.


Introduction: Isolated acquired ACTH deficiency is rare; it may be due to hypophysitis and association with other autoimmune diseases was reported.

Case report: E.L, female, aged 34, was diagnosed with primary autoimmune hypothyroidism and premature ovarian failure; levothyroxine and estroprogestins were administered. Suddenly, the patient developed vomiting, shivers without fever and soon coma installed, with tonic-clonic seizures. There was no history of recent pregnancy or traumatic injury. Biochemical data revealed severe hyponatremia (<100 mmol/l) with normokalemia (4.2 mmol/l); thyroid function was normal on L-T4 therapy (TSH=1.91 mIU/l, FT4=1.2 ng/dl). Adrenal deficiency was suspected. I.v. dexametasone 24 mg/day and saline were administered, with progressive, slow normalisation of natremia, followed by remission of coma and seizures. Further tests supported isolated ACTH deficiency: decreased plasma 0800 h cortisol (2.6 μg/dl), with low normal ACTH levels (8.2 pg/ml). Short Synacthen test (250 μg) showed inadequate cortisol stimulation (9.9 μg/dl at 30 min, 13.6 μg/dl at 60 min) and prolonged ACTH stimulation test (3 days) revealed adequate cortisol stimulation at 24 h (39.8 μg/dl), 48 h (31.1 μg/dl) and 72 h (43 μg/dl). Insulin tolerance test could not be performed due recent history of seizures, but insufficient response to glucagon test (maximum cortisol levels=10.9 μg/dl) supported the diagnosis. All other pituitary hormones were in normal range. Cerebral and pituitary MRI, adrenal CT scans were normal. Hydrocortisone 20 mg/day was administered, with maintenance of normal natremia and kalemia. Low sodium levels were reported in 28% of cases with isolated ACTH deficiency, but hyponatremic coma was very seldom reported.

Conclusion: This case emphasis the importance of considering isolated central adrenal insufficiency when encountering hyponatremic coma.

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