Endocrine Abstracts

57 years old male with past history of hypertension, was diagnosed with severe aortic valve regurgitation, dilated aorta and left ventricle while being worked up for cough and exertional shortness of breath. He was a nonsmoker with active lifestyle and no alcohol intake. He was admitted for elective mechanical aortic valve replacement and reimplantation of coronary arteries. On the day of surgery (day 0) his haemoglobin dropped from 157 to 73 g/l post operatively for which he received blood transfusions. On day 5, he underwent a repeat procedure due to chest wall bleeding. This was further complicated by heparin induced thrombocytopenia (HIT) and aortic valve abscess. On day 8 he developed mild hyponatremia and orthostatic hypotension. Hyponatremia work up showed low cortisol levels with investigations summarised below in table. He did not receive any intra-operative steroids or medications that could lower cortisol level. He was clinically diagnosed with primary adrenal insufficiency on the day of low cortisol presumably secondary to bilateral adrenal haemorrhages. Hyponatremia and postural hypotension improved within 2 days of starting intravenous hydrocortisone replacement. After being managed for 21 days in cardiac intensive care unit, he clinically improved. Subsequently, he was discharged with oral hydrocortisone replacement and fludrocortisone with discharge advice on sick day rules. As per the MDT discussion, the plan was to repeat his CT adrenals in 3 months’ time. During admission he was also managed for atrial fibrillation, upper limb occlusive thrombus and HIT under guidance of haemotology team. At the time of writing up this case, he was due for a repeat CT Adrenals followed by Endocrine clinic appointment. He has been doing well post discharge with no further hyponatremia and no symptoms suggesting orthostatic hypotension.