(263) A Classic Case of Adrenal Crisis Provoked by COVID-19 in Prolonged Undiagnosed Addison Disease

Introduction: Addison’s disease (AD) or primary adrenal insufficiency, is a rare disorder of the adrenal glands from adrenal cortex damage leading to insufficient hormone production of cortisol and sometimes aldosterone. Adrenal crisis (AC) is a life-threatening complication of adrenal insufficiency with main presentation of hypotension or hypovolemic shock. We present a classic and rare case of AC provoked by COVID-19 in a setting of prolonged undiagnosed AD.

Description: In July 2024, a 62-year-old female, with no PMH, presented to the ED due to failure to thrive & extreme fatigue for one month with associated appetite loss, weight loss, weakness, dizziness, & obtundation.

In 2012 she had multiple life stressors and since noted progressive skin darkening & poor appetite with weight loss. She had COVID-19 in February 2024 & since she developed progressive fatigue, worsened appetite, & a 30-pound weight loss.

On arrival, she was lethargic & hypotensive in the 70s/40s & had a BMI of 12.66. She was given fluids and an NG tube was inserted and was admitted to the floor. Her initial blood tests showed: Glucose 40 mg/dL, Sodium 123, Potassium 5.2, Bicarbonate 13 (mMol/L), Anion gap 10. Subsequent labs demonstrated low evening Cortisol of 1.6 ug/dL, low Aldosterone of < 4.0 ng/dL, and high Renin activity of 8.2. ACTH was 39.6 pg/mL at 13 hours after stress dosing steroid therapy (initial ACTH was not resulted). DHEA-S was low at 6.2 ug/dL at 2 days after steroid therapy.

She was transferred to the ICU due to hypotension requiring for pressors despite fluid resuscitation. Stress dosing hydrocortisone was initiated. Her pressor requirements were progressively weaned off after three days of stress dose steroid initiation and fatigue, weakness, & appetite significantly improved.

Discussion: In this case report, we highlighted a classic case of AC with prolonged undiagnosed AD presenting with hypovolemic and distributive shock, extreme fatigue, poor appetite, weight loss, hyperpigmentation, hypoglycemia, hyperkalemia, and hyponatremia. A formal ACTH stimulation test is needed for the diagnosis of AD. Clinicians should maintain a high index of suspicion of adrenal insufficiency. Early recognition of AC and prompt initiation of stress dosing steroid treatment are crucial for improving outcomes in these patients.