Primary adrenal insufficiency secondary to bilateral adrenal metastases: can extreme hyponatremia be compatible with life?

Silva Leandro Augusto; Elvas Ana Rita; Fernandes Andreia Martins; Joana Couto; Martins Raquel G.; Teresa Martins; Jacinta Santos; Andreia Matos; Fernando Rodrigues

doi:10.1530/endoabs.110.EP71

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Endocrine Abstracts (2025) 110 EP71 | DOI: 10.1530/endoabs.110.EP71

ECEESPE2025 ePoster Presentations Adrenal and Cardiovascular Endocrinology (170 abstracts)

Primary adrenal insufficiency secondary to bilateral adrenal metastases: can extreme hyponatremia be compatible with life?

Leandro Augusto Silva ¹ , Ana Rita Elvas ¹ , Andreia Martins Fernandes ¹ , Joana Couto ¹ , Raquel G. Martins ¹ , Teresa Martins ¹ , Jacinta Santos ¹ , Andreia Matos ² & Fernando Rodrigues ¹

Author affiliations

¹Portuguese Institute of Oncology of Coimbra Francisco Gentil, Coimbra, Portugal; ²Local Health Unit of Coimbra, Coimbra, Portugal

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Introduction: Severe hyponatremia is associated with high mortality, with severity linked to its etiology and the speed of onset. Primary adrenal insufficiency should be considered, bearing in mind that, although rare, bilateral adrenal metastases can be a potential cause.

Clinical case: A 53-year-old male was admitted at emergency room with confusion and diarrhea. His medical history included plurimetastatic lung adenocarcinoma. On examination, he presented with hemodynamic instability and hyperpigmentation of the skin and mucosae. Blood gas analysis revealed metabolic acidosis compensated by respiratory alkalosis and unmeasurable sodium level. Analytical workup showed Na⁺<100 mmol/l (RR 136-146), K⁺ 5.5 mmol/l (3.5-5.1), serum osmolality 214 mOsm/Kg (260-302), ACTH 615 pg/ml (9-52), urinary Na⁺ 43 mmol/l and urinary osmolality 423 mOsm/Kg (300-900). Based on clinical presentation, medical history and laboratory findings, a diagnosis of symptomatic hypovolemic hypoosmolar hyponatremia secondary to primary adrenal insufficiency due to bilateral adrenal metastases was made. The patient started treatment with intravenous hydrocortisone and fluid therapy, leading to clinical improvement and was subsequently admitted for continued care. One year after this acute event, the patient remains stable under clinical follow-up in Endocrinology and Medical Oncology, on hydrocortisone (20 mg) and fludrocortisone (0.1 mg) treatment, with stable neoplastic disease under systemic palliative therapy.

Conclusions: Extreme hyponatremia (<100 mmol/l) is rare and potentially fatal. In oncology patients, it requires clinical suspicion due to nonspecific symptoms often attributed to progressive neoplastic disease or antineoplastic therapy. Its etiology must be determined along with ensuring a safe correction. Severe hyponatremia caused by primary adrenal insufficiency is extremely rare in the literature. Although adrenal metastases are not uncommon in oncology patients, the prevalence of resulting primary adrenal insufficiency is notably low. The prognosis for these patients is generally very poor. However, as this case illustrates, advancements in oncological treatments have significantly improved outcomes.