Category: Adrenal Disorders

Monitor: 21

21 - ADRENAL INSUFFICIENCY MASQUERADING AS MENINGO-ENCEPHALITIS: A CASE REPORT

Saturday, Apr 27
10:30 AM – 11:00 AM

Objective : To report a case of adrenal insufficiency that presented with fever and altered mental status mimicking viral encephalitis.


Methods : n/a


Results : n/a


Discussion :

 A 64 year old female presented with fever, slurred speech and altered mental status. She had similar presentations twice in the past diagnosed as aseptic viral meningitis. Her past medical history included hypothyroidism, depression and asthma. Her medications included Levothyroxine and Fluticasone inhaler. On exam the patient was noted to be febrile: 101.6 F, normotensive: 108/71 mmHg, with pulse 76 bpm and 96% SaO2. She was confused and disoriented. Her Neck was supple with negative Kernig’s and Brudzinki signs. Remaining exam was unremarkable. Labs were significant for hyponatremia: 130 mmol/l with normal potassium 4.0 mmol/L and normal white blood cell count 5.75 K/uL. Lactate and liver function tests were normal. CT head was negative for an acute intracranial process. Lumbar puncture was performed and patient was started on IV ceftriaxone, Vancomycin and Acyclovir. She was admitted with preliminary diagnosis of viral meningo-encephalitis. CSF results were essentially normal. Infectious diseases were consulted who recommended stopping the antibiotics and continuing on Acyclovir alone. An AM Cortisol level was checked as part of the hyponatremia work up which was abnormal at 0.2 mcg/dl.  Cosyntropin test was performed which revealed an inadequate response confirming adrenal insufficiency. The patient was started on stress dose steroids after which her mental status markedly improved. Levels of adenocorticotropic hormone (ACTH), Follicle stimulating hormone (FSH), Luteinizing hormone (LH), Insulin-Iike growth factor 1(IG4-1) were all abnormally low and MRI brain showed a partially empty sella morphology thus confirming hypopituitarism. Further imaging with a CT abdomen/pelvis was performed which revealed bilateral atrophic adrenal glands with no masses. Acyclovir was discontinued on Day 4 once HSV PCR results were negative. By Day 5, the patient was fully oriented with improved energy and she was transitioned to oral steroids.


Conclusion :

Endocrine disorders can present with a wide range of neurological symptoms ranging from headache to acute encephalopathy. They can also cause symptoms mimicking an infection such as fevers and diarrhea. Early diagnosis and treatment can rapidly relieve the symptoms whereas delayed diagnosis can be life threatening. In this case, the patient had prior two similar presentations that had been likely misdiagnosed as viral meningitis. In a patient presenting with altered mental status and electrolyte abnormalities, an endocrine disorder should always be considered as a differential diagnosis. 

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Mariam R. Saand

Internal Medicine Resident
Englewood Hospital and Medical Center
Englewood, New Jersey

PGY2 internal medicine resident at Englewood Hospital and Medical Center, NJ. Originally from Pakistan. Interested in pursuing Endocrinology for fellowship.

Ahmad Alkhataneh

Internal Medicine Resident
Englewood Hospital and Medical Center

PGY2 resident at Englewood Hospital and Medical Center, NJ

Mariam R. Saand

Internal Medicine Resident
Englewood Hospital and Medical Center
Englewood, New Jersey

PGY2 internal medicine resident at Englewood Hospital and Medical Center, NJ. Originally from Pakistan. Interested in pursuing Endocrinology for fellowship.

Huwad Choudhry