Challenges in the Diagnosis and Management of Adrenal Insufficiency

Abstract

Adrenal insufficiency (AI) is a rare endocrine condition. Primary adrenocortical insufficiency, or Addison diseases reduces the production of crucial hormones, including glucocorticoids, mineralocorticoids, and adrenal androgens. Due to the lack of proper cortisol response in adrenal crisis, it can be life-threatening during times of stress, emphasizing the need for a timely diagnosis. Despite this, diagnosing and managing AI still presents significant challenges. We report the case of a middle-aged woman who presented with complaints of weight loss, abdominal
pain, lethargy, hyperpigmentation of the skin and mucosa, and a history of repeated hospitalizations for nausea, vomiting, dehydration, and hypovolemia. During the patient's previous hospitalization, Addison's crisis was suspected, and methylprednisolone therapy was administered, rendering the cortisol and ACTH assays inaccurate. The patient's condition subsequently improved. The subsequent monitoring revealed low cortisol levels, but an ACTH stimulation test was unavailable. The presence of pulmonary tuberculosis was indicated by a positive chest X-ray and IFN-Gamma Release Assay (IGRA) test. With a history of repeated hospitalizations, suspected Addison's crisis, hypoglycemia, mineralocorticoid involvement (hypotension, hyponatremia), and the presence of hyperpigmentation, a clinical diagnosis of primary adrenal insufficiency was made with limited conditions and testing tools. The patient was given anti-tuberculosis treatment and the lowest dose of hydrocortisone required to control the disease without causing side effects.