Category: Pituitary Disorders/Neuroendocrinology

Monitor: 22

22 - COMING IN FROM THE COLD: UNUSUAL PRESENTATION OF SECONDARY ADRENAL INSUFFICIENCY

Thursday, Apr 25
1:00 PM – 1:30 PM

Objective : Adrenal insufficiency (AI) is not common but may be life threatening resulting in an adrenal crisis with electrolyte derangements, altered mental status or even shock. AI can present as a primary or secondary process. Overall, the number of patients with secondary AI greatly exceeds those with primary AI. Prevalence of secondary AI has been estimated to be 40-110 cases per million (USA).The most frequent cause is exogenous steroid use, though clinical relevance of this insufficiency may be difficult to assess. We will present a case of an unusual presentation of secondary adrenal insufficiency.


Methods : n/a


Results : A 57 year old male presented with hypothermia and altered mental status after falling in the shower. Patient had history of hypertension, alcohol abuse and liver cirrhosis. In the ER he was agitated and intubated for airway protection. Bradycardia (50) and hypothermia (95.2 F) with BP 150/90 noted. Sodium was 145, Potassium 4.5. Treatment for possible sepsis was initiated but was not an issue. CSF exam was normal. Hepatic encephalopathy treatment was started. Clinical improvement of hypothermia was modest with IV fluids and rewarming. Standard Cosyntropin test was rapidly performed with baseline ACTH 6 (6-50), baseline cortisol  0.6, 30 minute cortisol 2.2  and 1 hour cortisol 3.1.  Patient was euthyroid by labs. Remainder of pituitary functions were normal. After testing, stress dose of hydrocortisone was started with prompt improvement of mental status and resolution of the hypothermia. Further history at that time revealed patient was taking Prednisone for an unknown amount of time two years ago for "alcoholic hepatitis". Patient fully recovered and discharged on oral replacement hydrocortisone.



Discussion : This patient had a flat response to Cosyntropin with a low baseline ACTH level. Hypothermia in our case may have been due to a lowered basal metabolic rate and dysfunction of the response system. This situation can have devastating consequences and early detection of the underlying pathology is vital to prevent morbidity and mortality. Adrenal insufficiency must be considered in the differential diagnosis of hypothermia. Also, secondary adrenal insufficiency must be considered when a patient has been on any dose of steroids for an unknown duration. Our patient did not have typical lab features of secondary adrenal insuficiency such as hyponatremia or clinically appreciable deficits of other pituitary hormones thus slowing consideration of the ultimate diagnosis of secondary AI.


Conclusion : Secondary adrenal insufficincy can be a remediable metabolic cause of hypothermia. In the proper clinical setting, prompt adrenal testing and timely use of stress dose steroids is indicated.

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Richard W. Pinsker

Internal Medicine Residency Program Director
Jamaica Hospital Medical Center
East Williston, New York

Program Director Internal Medicine Residency, Associate Chairman Department of Medicine for Medical Education, Jamaica Hospital and Medical Center, New York. COL (R), USARNG, MC.

Tahmina Jahir

Resident, Internal Medicine
Jamaica Hospital Medical Center
Jamaica, New York

PGY-2 Resident in Internal Medicine

Sudheer Chauhan

Associate Program Director Department of Medicine
Jamaica Hospital Medical Center
Jamaica, New York

Associate Program Director, Department of Medicine, Jamaica Hospital Medical Center, New York

Narinder Kukar

Director, Department of Endocrinology
Jamaica Hospital Medical Center
Jamaica, New York

Director, Department of Endocrinology, Jamaica Hospital Medical Center, New York. Dr. Narinder Kukar is an endocrinologist by profession and the director of Endocrinology and Diabetes at a major teaching Hospital in New York.

In 1968 Dr Kukar founded the SMS Medical College Jaipur Alumni Association which is now known as RAJMAAI. He has published numerous articles in the field of medicine as well as on diverse topics such as Indian culture and politics, Hinduism, Democratic vs. Theocratic Societies and Dictatorial States.

In addition to his distinguished service to the medical profession, he has served as national president and the chairman of the board of trustees of the Association of Indians in America (AIA 1992 - 2001)

Dr. Kukar’s contributions have been recognized in many forums. He is the recipient of many awards, including excellence in teaching (1994), distinguished achievement award (1994), vision and leadership award (1997), News India Times Leadership Award (1997), Shanti Fund Unique Achievement Award (1999), Shiromani Award (2001) by RANA (Rajasthan Association of North America) as well as the Highlights recognition: India Tribune Newspapers (March 2, 2002),
Nassau county community award 2009 and many others.

Dr. Kukar is also active in community service. He is a man of principle and has the uncommon ability to speak the truth in any setting. His vision, the courage of his convictions, perseverance, motivational charm, and oratorical skills have made him a respected leader and a guiding spirit of the Indian Community.