8741 Stepping Into The Silent Storm: Unmasking Adrenal Insufficiency In The Elderly
Authors: Plaza Mejias Carmen Nahir , Medina Torres Wilnelia , Valerio Pérez Leidy , Pérez Mitchell Maria , Revilla Orellano Radames , Jiménez Velázquez Ivonne 
Published: October 2024

Abstract
Disclosure: C.N. Plaza Mejias: None. W. Medina Torres: None. L. Valerio Pérez: None. M. Pérez Mitchell: None. R. Revilla Orellano: None. I. Jiménez Velázquez: None.
Adrenal insufficiency (AI) is a complex endocrine disorder characterized by inadequate hormone production or impaired function, crucial for maintaining physiological equilibrium. Manifestations vary from subtle nonspecific symptoms to life-threatening complications, with diverse causes including autoimmune destruction, infections, and medication-induced suppression. This abstract details a case of a staggered presentation of signs and symptoms of AI with normal laboratory results, making the diagnosis a challenge. The patient, an 80-year-old female patient with a history of hypothyroidism, hypertension, diabetes mellitus type 2 with neuropathy, and an unspecified neurocognitive disorder, presented to the ED with nausea, vomiting, anorexia, and abdominal pain for several days. Patient was admitted for severe hyponatremia after her condition was complicated by altered mental status and a seizure episode requiring administration of 3% NSS. On evaluation, the patient was found awake, alert, and oriented only in person (baseline as per family members), hemodynamically stable, and in no acute distress. Examination was remarkable for dry oral mucosa and poor skin turgor. Normal saline 0.9% was provided to restore volume status. Laboratory work-up revealed decreased serum osmolarity, and elevated urine osmolarity and sodium, suggestive of euvolemic hypotonic hyponatremia and raising suspicion for the Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Exclusion of possible etiologies such as traumatic brain injury, surgery, tumors, or medications, narrowed down the source to an infectious process, considering the patient's recent periodontal procedure. Following the elimination of other causes of hyponatremia such as hypothyroidism and thiazide use, the Endocrinology service initiated salt tablets and fluid restriction. Despite initial management, the hyponatremia persisted, leading to a diagnostic dilemma. The absence of hypotension, hyperkalemia, salt craving, skin hyperpigmentation or other classic signs or symptoms, made glucocorticoid deficiency less likely. Cortisol levels and ACTH were relatively within normal range. New onset of recurrent hypoglycemic episodes followed by hypotension prompted reassessment. A trial of steroids led to notable improvement and recurrence of symptoms after discontinuation, pointed towards the diagnosis. DHEAS was obtained, and prednisone therapy was reinitiated. This case highlights the insidious nature of AI and its diagnostic challenges. It emphasizes the importance of clinical vigilance particularly when patients present with unexplained and nonspecific symptoms that mimic other medical conditions. In conclusion, a comprehensive approach to differential diagnosis is essential to facilitate diagnostic accuracy and timely intervention to prevent potentially life-threatening complications.
Presentation: 6/1/2024