SAT-429 - Recurrent Adrenal Crisis with Severe Hyperkalemia Despite Reassuring Initial Bedside and Electrocardiographic Findings

Background:
Adrenal crisis is a time-sensitive endocrine emergency in which the severity of illness may be underrecognized early in the course. When bedside assessment underestimates biochemical severity, diagnosis and treatment may be delayed. This discordance may occur even in patients with known primary adrenal insufficiency.

Clinical

Case:
A 32-year-old woman with autoimmune polyglandular syndrome type 2 (primary adrenal insufficiency, type 1 diabetes mellitus, and autoimmune hypothyroidism), and chronic kidney disease presented with 12 to 16 hours of fatigue, dyspnea, anorexia, weakness, and impaired ambulation despite doubling her home oral hydrocortisone after recognizing symptoms similar to prior crises requiring admission. On arrival, temperature was 98.1°F, heart rate 80/min, respiratory rate 14/min, blood pressure 105/71 mmHg, and oxygen saturation 99% on room air. She was alert and oriented with dry mucous membranes and no focal neurologic deficits. However, the severity of illness became apparent only after laboratory evaluation obtained several hours after presentation revealed sodium 126 mmol/L (135-145), potassium 8.6 mmol/L (3.5-5.0), bicarbonate 19 mmol/L (22-29), creatinine 1.81 mg/dL (0.6-1.1; baseline 1.2), magnesium 1.4 mg/dL (1.7-2.2), free T4 0.4 ng/dL (0.8-1.8), and TSH >150 mIU/L (0.4-4.5). Anion gap was not elevated, beta-hydroxybutyrate was negative, and ECG showed sinus rhythm without classic hyperkalemic changes.

She received hydrocortisone 100 mg IV followed by stress-dose hydrocortisone, isotonic saline, insulin with dextrose, sodium zirconium cyclosilicate, calcium gluconate, and magnesium and was admitted to the intensive care unit for severe hyperkalemia. Persistent hyperkalemia required continuous insulin-dextrose infusion before normalization. IV levothyroxine was started after glucocorticoid coverage had been established. She improved clinically, renal function returned to baseline, and she was discharged on hospital day 6 on home hydrocortisone, fludrocortisone, and levothyroxine.

Clinical Lessons:
Adrenal crisis may present with profound electrolyte derangement despite an initially low-acuity bedside impression and unremarkable ECG. Intravenous hydrocortisone should be administered promptly when adrenal crisis is suspected rather than deferred pending biochemical confirmation because treatment is time-sensitive and clinical severity may be underestimated early in the course. In recurrent presentations, patient-recognized symptom patterns from prior adrenal crises may provide an important early diagnostic clue even when initial vital signs, examination, and ECG are not overtly alarming.

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