Endocrine Abstracts

Introduction: Adrenal crisis due to primary adrenal insufficiency may result in severe morbidity and mortality if undiagnosed or ineffectively treated. Main manifestations are hypotension (>90%), hyponatremia (70–80%), and hyperkalemia (30–40%), while hypoglycemia is rare. An unusual case of a septic patient with hypokalemia and hypomagnesemia with hypoglycemic coma as first manifestation of acute adrenal insufficiency is presented.

Case presentation: A 51-yr-old woman, with tetraparesis after a cervical spine fracture 20 years ago, was admitted to Intensive Care Unit for septic shock due to osteomyelitis of the right hip. She received empirically several antimicrobials such as vancomycin, amikacin, daptomycin, tigecyclin and high doses of fluconazole. After clinical improvement, she was transferred to the Department of Orthopedics, where she started to complain of anorexia, fatigue, nausea and polyuria. Laboratory tests revealed normal serum sodium, hypokalemia and hypomagnesemia due to increased urine losses of respective cations, nephrogenic diabetes insipidus and renal tubular acidosis. A month later, she had two episodes of seizures with subsequent loss of consciousness. Her blood pressure was low (85/56 mmHg). Laboratory evaluation showed very low blood glucose levels, confirming the diagnosis of hypoglycemic coma. Hormonal evaluation revealed low levels of cortisol and aldosterone with high levels of ACTH and renin, indicating acute adrenal failure. Abdominal CT scan showed normal size adrenal glands, with no sign of adrenal hemorrhage. Investigation for infections such as tuberculosis, fungi, CMV and HIV, commonly associated with primary adrenal insufficiency, was negative. Previous fluconazole therapy was considered as the most possible etiology of adrenal dysfunction. Hydrocortisone replacement treatment led to restoration of blood glucose and blood pressure levels. It is remarkable that, despite adrenal insufficiency, severe hypokalemia and the associated nephrogenic diabetes insipidus, resisted and were both restored only after correction of serum magnesium.

Conclusion: Fluconazole in high doses may inhibit adrenal steroidogenesis and may cause adrenal failure. In addition, antibiotics commonly used in acutely ill patients, such as amikacin, may cause renal damage, with electrolyte disturbances, such as hypomagnesemia and hypokalemia. The diagnosis of acute adrenal failure caused by fluconazole may be obscured in septic patients with antibacterial-induced renal damage. Sudden appearance of severe hypoglycemia in such patients must be taken into account as a sign of adrenal insufficiency and must be investigated and treated appropriately.