SAT-439 - A Case of Primary Adrenal Insufficiency in A Young Adult: A Case Report

Introduction:
Adrenal insufficiency is an uncommon but potentially life-threatening condition that can present subtly with orthostatic symptoms, electrolyte abnormalities, and hypoglycemia. This case highlights the importance of maintaining a high index of suspicion for adrenal insufficiency (AI) in patients presenting with dizziness and orthostatic hypotension, especially when laboratory abnormalities are present.

Case presentation:
A 23 yr-old young male of Korean and Irish descent with subclinical hypothyroidism and vertigo presented to the Emergency Department (ED) for a recent adenovirus causing upper respiratory infection, due to lightheadedness upon standing or activity for 2 days. He denied episodes of syncope but had one fall on the prior day. Pt’s vitals were orthostatic positive: BP 138/66 mmHg sitting and 98/52 mmHg on standing with no change in HR 72. Laboratory data revealed: Serum sodium was 125 mmol/L (normal 135–145), potassium 4.8 mmol/L (normal 3.5–5.1), fasting serum glucose 61 mg/dL (normal 70–99) with point-of-care glucose 70 mg/dL (normal 70–140). Serum cortisol was low at 0.67 µg/dL (normal morning range 6–23). Thyroid studies showed an elevated TSH of 7.33 µIU/mL (normal 0.4–4.5) with normal free T3 3.24 pg/mL (2.3–4.2) and normal free T4 1.09 ng/dL (0.8–1.8). EKG-sinus rhythm, QTc of 460ms. IV NS bolus 1000mL was administered in ED. Endocrine was consulted due to suspicion of AI. Further evaluation showed positive ACTH stimulation test of >1250 pg/mL (0-47) confirming AI with elevated B12 level 7.339 pg/mL (193-986), negative tissue transglutaminase Ab test < 1.0 ( < 15.0), normal repeat TSH of 2.702 uIU/mL (0.550 – 4.780) and normal type 1 DM work up (negative endomysial antibody and islet cell antibody w/ IA2 Ab of < 5.4 U/mL). Pt was initially treated with IV Hydrocortisone and transitioned to oral hydrocortisone and fludrocortisone. He was discharged with negative orthostatic symptoms/vitals and was prescribed hydrocortisone 10 mg in morning and 5 mg in the afternoon with fludrocortisone 0.05 mg daily.

Discussion:
This patient presented with lightheadedness and orthostatic hypotension following a recent viral illness, a scenario in which symptoms could easily be attributed to dehydration or post-viral autonomic dysfunction. This case highlights the importance of pursuing further endocrine work up in patients with dizziness and orthostatic hypotension, especially when accompanied by electrolyte disturbance or hypoglycemia. Timely diagnosis and treatment resulted in rapid clinical improvement and resolution of orthostatic symptoms, emphasizing the value of early intervention.

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