Case Presentation: A 42 year old female with history of pain, anxiety, depression, substance use disorder, and atrial septal defect who was admitted for workup of 6-7 months of fevers at home. She had been admitted about 1 month prior for workup of fever of unknown origin. Workup at that time revealed candida esophagitis, but infectious workup, including human immunodeficiency virus (HIV), quantitative immunoglobulins, transthoracic echocardiogram (TTE), rheumatologic workup, CT of abdomen and pelvis, and cultures were otherwise negative. She did leave against medical advice prior to completion of her workup, but was given a course of fluconazole for her candida esophagitis. Upon her repeat presentation, the patient complained of continued fevers at home of up to 99.4 degrees Fahrenheit, dizziness, generalized weakness, syncopal episodes, nausea/vomiting, weight loss and diffuse body pain. She did not have any cough, dysuria, nausea, vomiting or diarrhea. She did admit to the illicit use of opioids, benzodiazepines and marijuana use as a way of self-treating her anxiety and pain. Physical exam revealed fevers of up to 102.7 degrees Fahrenheit, low-normotensive blood pressures and poor dentition. Exam was unremarkable.Infectious disease was consulted given her prior workup. Multiple sets of repeat cultures were drawn at separate intervals which returned negative. On lab work, she did have significant microcytic anemia as well as highly elevated inflammatory markers. Repeat workup including rheumatologic serologies, HIV, syphilis, thyroid hormone, chest imaging, TTE, urinalysis were once again negative. In addition, a panorex and thrombotic was done which did not reveal a source of infection. Hematology was consulted who ordered a bone marrow biopsy which also returned with no significant findings.Her cortisol did return low and thus a cortisol stimulation test was completed which returned positive for adrenal insufficiency (AI). Endocrine was consulted and patient was started on steroids which eventually lead to an improvement of her fevers.

Discussion: Our patient’s cause of fevers was thought secondary to adrenal insufficiency. Although fever of unknown origin is a rare presentation for AI, there are some studies which show that this is a potential way that AI can present(1). Our patient also had more typical symptoms of AI including such as her weakness, nausea/vomiting, and fatigue(2). The cause of AI for our patient was thought to be due hypothalamic-pituitary-adrenal axis suppression from her chronic opioid use(3).

Conclusions: Fever of unknown origin is a rare presentation for adrenal insufficiency and can be missed in favor of an infectious workup.