SAT-058 - Syncope Due to Central Adrenal Insufficiency in A Patient with Idiopathic Intracranial Hypertension

Introduction:

Idiopathic Intracranial Hypertension (IIH) is characterized by increased intracranial pressure, normal cerebrospinal fluid, and relatively normal neuroimaging studies. It primarily affects overweight women of childbearing age, causing headaches and papilledema. Here, we present a case of IIH complicated by central adrenal insufficiency (AI) resulting in syncope.



Case presentation:

A 28-year-old woman with a history of IIH was found down with a blood glucose of 33 mg/dL (70-111 mg/dl). She was given 1 ampule of dextrose and brought to the hospital by EMS. Endocrinology was consulted for recurrent hypoglycemia despite D10 drip on hospital day 2. Review of systems revealed a 50-pound unintentional weight loss and anorexia. She denied steroid or opioid use or a history of head trauma. She had an uncomplicated pregnancy 18 months prior and regular menses since. Physical exam was unremarkable. Initial labs noted hyponatremia to 131 mEq/L (135-145 mEq/L) and cortisol < 1 ug/dL (4.0 - 20.0 ug/dL). Further labs showed ACTH < 1.0 pg/mL (7.2 - 63.3 pg/mL), DHEA-S 5 ug/dL 35 – 430 ug/dL), TSH 3.4 uU/mL (0.30 - 4.20 uU/dL), FT4 0.8 ng/dL (0.6 - 1.5 ng/dL), HCG < 6. She was also found to be COVID-19 positive. MRI brain showed flattening of the pituitary gland along the floor of the sella turcica without a sellar mass. Her transthoracic echocardiogram revealed left ventricular hypokinesis with an ejection fraction of 47%. She was treated with stress dose steroids with improvement. Steroids were tapered and she was discharged on physiologic dose of hydrocortisone with sick day rule counseling.



Discussion:

This case highlights an underrecognized but clinically important association between IIH and overt central AI with delayed diagnosis of AI. In one cohort of IIH patients, nearly 70% had partial empty sella. Over one-third had hormonal abnormalities, including low cortisol levels in approximately 20%, independent of empty sella. In this case, central AI was suspected to result from pituitary dysfunction related to partially empty sella from chronically elevated intracranial pressure. Longstanding weight loss and anorexia likely reflected undiagnosed AI that was acutely exacerbated by the stress of COVID-19 infection, precipitating hypoglycemia, hyponatremia, and syncope. Cardiac manifestations may have represented cardiac dysfunction related to prolonged cortisol deficiency vs stress-related COVID myocarditis. Prompt initiation of hydrocortisone led to rapid symptom resolution, highlighting a clinically actionable diagnosis that may otherwise be overlooked in IIH patients.

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