Case Presentation: A 22 year-old G1P1000 pregnant woman at 24 weeks presented with hypertensive urgency and newly diagnosed intrauterine growth restriction in the setting of pre-eclampsia. On admission her physical exam and laboratory data were unremarkable. The patient was admitted to maternal fetal medicine for closer fetal monitoring. On hospital day (HD) 9 she began to develop anasarca. Labs showed a sodium of 122, potassium of 5.4, and nephrotic range proteinuria. She was transferred to medicine for management of severe hyponatremia, with a differential diagnosis including nephrotic syndrome and adrenal insufficiency (AI). A work up was initially concerning for secondary AI, with low AM cortisol, low-normal ACTH, and a suboptimal cosyntropin test. No abnormality was found on abdominal MRI or non-contrast brain MRI to support primary or secondary adrenal insufficiency. Further evaluation with contrast studies was limited by her pregnancy, so she was empirically started on high dose steroids for possible secondary AI. On HD 15, the physicians on consult teams transitioned. The new endocrinologists questioned the diagnosis of secondary AI given no supporting evidence in her extensive workup. A thorough review of her medication history revealed that on HD one and two, the patient received betamethasone for potential emergent delivery. Case reports have described betamethasone causing tertiary AI. A prednisone taper was initiated and further workup for secondary AI was terminated. The patient was successfully tapered off of systemic steroids. Her fluid overload and electrolyte abnormalities resolved with medical management.
Discussion: Many hospitalized patients have prolonged hospital courses that involve transfers between transitioning providers, between services when alternate specialty care is indicated, or between hospitals. It is very common for providers receiving the care of a patient from another team to accept an existing working diagnosis. However, to avoid anchoring bias for patients with extensive hospital courses, all involved providers must independently review the prior hospital events and objective data during transitions of care. In this case, the inpatient medicine team and initial endocrine consult team pursued an extensive inconclusive work-up and empiric treatment for secondary AI, including two MRIs, multiple serum and urine analyses, and a prolonged high-dose steroid course. Betamethasone, a highly potent steroid, can cause prolonged suppression of ACTH which leads to suppression of cortisol. Case reports have described exposure to a few doses leading to tertiary AI. This work-up may have been avoided with a more thorough review of the patient’s past hospital course, medication administration history, and consideration of alternative differential diagnosis.
Conclusions: Independent and thorough review of prior hospital events and objective data should be performed by all members of the treatment teams during transfers of care, especially when the initial working diagnosis is unclear, to avoid anchoring bias.