resident year 2 NYCMC Metropolitan New York, New York, United States
Introduction : Adrenal insufficiency (AI) has been recorded in 9%-83% of stable cirrhotic patients. AI has been described in all stages of cirrhosis, including critically ill or stable patients. Some studies even argue that adrenal failure is a feature of liver dysfunction. However, making a diagnosis is challenging as the conventional diagnostic methods - serum total cortisol levels may be inaccurate due to changes in serum concentrations of cortisol-binding globulin (CBG) and albumin. We present a patient with a MELD score of 30 and Maddrey’s score of 129, with recurrent electrolyte abnormalities, who was presumed to have AI and responded to steroids.
Case(s) Description : A 41-year-old male with a past medical history of liver cirrhosis with esophageal varices status post banding, alcohol use disorder, and hypertension presented with a bitemporal headache of one-day duration. Initial labs showed hyponatremia of 125 meq/L and hyperkalemia of 6.8 meq/L. Given the low blood pressure, spironolactone, furosemide, and carvedilol were all held. With paracentesis, 4.7 L of fluid was removed, and albumin was infused. Despite this treatment, hyponatremia (123 meq/L) and hyperkalemia (5.3 meq/L) persisted. Random cortisol (3.3 ug/dL), AM ACTH (16.6 pg/ml), and AM cortisol levels were low (5.5 ug/dL), and repeat cortisol levels 30 and 60 minutes post cosyntropin challenge were all within the low normal range (10.8 ug/dL and 12.4 ug/dL respectively). The patient was started on hydrocortisone 10 mg in the morning and 5 mg in the afternoon. The next day, the patient’s electrolytes normalized, and the headache resolved. He was hemodynamically stable and was discharged.
Discussion : Cirrhosis and AI are both characterized by hyperdynamic circulatory failure, peripheral vasodilation, and low arterial pressure with high ADH levels. Our patient presented with hypotension, hyponatremia, hyperkalemia, and generalized weakness, which was attributed to liver cirrhosis. However, making a diagnosis is challenging as the conventional diagnostic method (serum total cortisol levels) may be inaccurate due to changes in CBG and albumin serum concentrations. It may overestimate the incidence of AI among cirrhotic patients as it measures both the bound and free cortisol levels. Thus, there is a tendency for some clinicians not to consider AI from the start.
In this case, we highlight the importance of early consideration of AI among cirrhotic patients, even when diagnosing it can be challenging. Prompt recognition of AI and administration of steroids is exceptionally vital; otherwise, complications may lead to detrimental consequences and death.
