FRI221 A Case Of Pulmonary Embolism Presenting As Adrenal Crisis

Abstract

Abstract Disclosure: S. Guntaka: None. C. Barron: None. P. Zhou: None. Introduction: Adrenal crisis is not a typical presentation for iatrogenic adrenal insufficiency. We present a case of pulmonary embolism (PE) with a history of steroid use, to show the complexity of diagnosing adrenal crisis caused by iatrogenic adrenal insufficiency. Case Presentation: A 19-year-old woman with a history of severe atopic dermatitis, was treated with high dose prednisone for three weeks. One month after completing the course, she presented to the ED with rash, mid-sternal chest pain, dizziness and shortness of breath. Vitals were significant for tachycardia and hypotension. BMP showed Na 129 mEq/L (135-145), K 6.1 mEq/L (3.5-5), glucose 140 mg/dl, BUN 22mg/dL (5-20), and Creatinine 1.25 mg/dl (&lt 1.2). EKG showed peaked T waves and chest X-ray was normal. Adrenal crisis was the initial impression due to the history of steroid use and electrolyte abnormalities. She received hydrocortisone 100 mg IV for 2 doses. Hyperkalemia was treated with a calcium gluconate bolus, albuterol, insulin and glucose. She continued to endorse difficulty breathing, and chest pain, and so other etiologies were considered. A V/Q scan demonstrated multiple v/q mismatched defects in bilateral lung fields, suggestive of PE. She was admitted for anti-coagulation therapy and showed clinical improvement, without additional steroid use. An ACTH stimulation test demonstrated adequate function of the hypothalamic-pituitary-adrenal axis with normal cortisol response. Baseline and post-stimulation androstenedione and 17OHP, aldosterone, plasma renin activity, DHEAS and TFTs were also normal. Extensive work-up for coagulative and autoimmune disorders was unremarkable. The patient was subsequently restarted on oral prednisone for worsening skin disease. Conclusion: Steroid use has been associated with the development of PE. Hyponatremia can be seen among patients with PE, occurring at rates of 21 to 26%.1 In contrast, secondary adrenal insufficiency presents with euvolemic hyponatremia, and uncommonly hypoglycemia. Hyperkalemia is not typically seen. Salt craving, postural dizziness, dehydration are also not common in secondary adrenal insufficiency as mineralocorticoid function is preserved. This case demonstrates the importance of evaluating for additional etiologies in the setting of hyponatremia with electrolyte abnormalities that are not usually seen with secondary adrenal insufficiency. This patient’s initial presentation is more consistent with PE and acute renal insufficiency. Understanding the presentation of iatrogenic adrenal insufficiency is necessary to make the correct diagnosis, and to ensure patients receive appropriate care.