Endocrine Abstracts

JOINT3800

Introduction: Adrenal insufficiency (AI) is a rare but potentially life-threatening condition that often remains undiagnosed until an acute illness or other major physiologic stress, such as surgery, occurs. Cortisol deficiency leads to unopposed insulin action, resulting in increased peripheral glucose uptake and decreased hepatic glucose output, leading to hypoglycemia. This case report describes a patient who developed severe hypoglycemia after cholecystectomy, which eventually led to the diagnosis of AI.

Case presentation: A 42-year-old female patient with no known comorbidities underwent elective laparoscopic cholecystectomy for symptomatic gallstone disease. Preoperative assessment, including fasting glucose and routine laboratory tests, was unremarkable. The surgical procedure was uneventful, and no intraoperative complications were noted. However, on the first postoperative day, she developed severe hypoglycemia with a documented blood glucose level of 1.6 mmol/l (28.8 mg/dl), accompanied by neuroglycopenic symptoms. She was immediately treated with 10% intravenous glucose, which led to a rapid improvement in symptoms. After this episode, the patient remained hemodynamically stable and experienced no further hypoglycemic events during her hospitalization. Because the initial hypoglycemic episode was unexplained and neither exogenous insulin, an oral hypoglycemic agent, nor an anesthetic known to induce hypoglycemia was used, an endocrinological consultation was requested. At discharge, she was provided with a continuous glucose monitor (CGM) and a glucometer to detect possible recurrent hypoglycemic episodes. At her first endocrinological follow-up with CGM, early morning hypoglycemic episodes were noticed. Morning cortisol levels (measured at 8:00 am) were low (160 nmol/l), with an inadequate rise in cortisol levels during the Synacthen stimulation test. In addition, elevated ACTH levels of 64 pmol/l and positive anti-21-hydroxylase antibodies confirmed an autoimmune cause of primary adrenal insufficiency. Screening for other autoimmune diseases, including celiac disease, autoimmune thyroiditis, primary ovarian insufficiency and pernicious anemia, was negative. The patient was started on hydrocortisone replacement therapy, with dose adjustments for physiologic stress such as infection, surgery, or trauma. A review of previous medical records revealed multiple emergency room visits for nausea, vomiting, hyponatremia, and renal acute insufficiency, suggesting preexisting adrenal dysfunction in acute illness.

Conclusion: While transient hypoglycemia due to fasting or anesthetics may occur in the postoperative period, severe hypoglycemic episodes should prompt further endocrinologic evaluation. Recognizing adrenal insufficiency as a potential underlying cause is crucial, as timely diagnosis and appropriate glucocorticoid replacement therapy can prevent life-threatening complications and improve the patient's prognosis.