Adrenal crisis presenting as an acute abdomen

Abstract

We report an interesting case of an ‘acute abdomen’. A 63-year-old female was admitted to the Emergency Department with a brief history of severe diarrhoea and rectal bleeding. Colonoscopic findings were normal. Over the next 24 h she developed lower abdominal pain with distension and became hypotensive. Her blood biochemistry results were sodium 133 mmol.l−1, potassium 5.3 mmol.l−1, urea 10.1 mmol.l−1 and creatinine 186 μmol.l−1 Suspecting peritonitis, surgeons performed a laparotomy which revealed a large quantity of uninfected peritoneal fluid, but no perforation of a viscus. Microbiological screening did not reveal any infection. In spite of all measures, she developed multi-organ failure and died a week later. Her past medical history included a head injury 35 years previously and she was maintained on carbamazepine and sodium valproate for post-traumatic seizures. She was hypothyroid on thyroxine supplementation. About 10 years prior to this admission she underwent Keller's operation on her foot and postoperatively had severe seizures and high fever. A few months later she underwent appendicectomy and had a difficult postoperative recovery with seizures and hyponatraemia (113 mmol.l−1), which was attributed to the syndrome of inappropriate ADH secretion secondary to her anti-epileptic medications. On another occasion she was admitted with tonsillitis and developed features of septic shock with a high fever and persistent hypotension requiring fluids and antibiotics. Her only uneventful hospital visit was for an orthopaedic procedure during which she was given a methyl prednisolone injection into her shoulder joint. At post mortem examination, despite a prolonged and extensive search, the adrenal glands were not identified. The thyroid gland was small and the pituitary fossa was considerably enlarged and the pituitary gland was largely replaced by non-functioning fibrous and calcified tissue. On review it appears complications during her previous hospital admissions could have been manifestations of adrenal insufficiency. The only uneventful hospital stay was when she had a steroid injection in her shoulder, which incidentally provided the steroid coverage during the stressful period. In this case, the adrenal failure could have been the result of the head injury she sustained several years earlier, resulting in damage to the pituitary gland. Against this possibility is the enlarged pituitary fossa found at autopsy. She had also suffered from unexplained episodes of headaches, perhaps due to a necrosed pituitary tumour? Histological examination of the pituitary gland revealed calcified and atrophic tissues. Similar cases have been described in the past where the cause was attributed to autoimmune adrenalitis [1]. Acute gastrointestinal symptoms and persistent unresponsive hypotension should raise the possibility of adrenal insufficiency. As our case demonstrates, missing this diagnosis can lead to unnecessary surgical exploration.