Case Presentation: Acute adrenal insufficiency (adrenal crisis) is life-threatening and requires prompt diagnosis and treatment. We present a case of adrenal crisis with delayed diagnosis and treatment due to a normal serum cortisol level, and we discuss the role of cortisol levels in diagnosing acute adrenal insufficiency. A 28-year-old male diagnosed with HIV, on treatment, presented with altered mental status. On physical exam, his blood pressure was 87/64 mmHg, temperature was 30°C, and his heart rate was 48 bpm. He was confused and encephalopathic; the rest of his physical exam was unremarkable. His labs showed glucose of 69 mg/dL, and a WBC of 2.6 K/CUMM; EKG showed sinus bradycardia with Osborn waves. He was initially resuscitated with warm saline, ampules of D50, and a Bair Hugger. IV antibiotics were initiated for sepsis as he is immunocompromised. Acute adrenal crisis was ruled out with a normal cortisol level of 19.1 mcg/dL at 23:00. When the patient’s condition remained critical without improvement, the decision was made to treat as for adrenal crisis with a stress dose of IV hydrocortisone and he completely recovered. Cosyntropin stimulation test (while holding hydrocortisone) was subnormal with cortisol rising from 9.3 mcg/dL to 17.3 mcg/dL at 60 minutes.
Discussion: Our patient possibly had subclinical hypoadrenalism secondary to HIV itself or an opportunistic infection and developed adrenal crisis from a viral syndrome. When a patient is under extensive stress, extremely high cortisol levels are expected. Although our patient’s cortisol levels were considered to be within normal limits, his drastic clinical improvement in response to hydrocortisone treatment led to the diagnosis of adrenal insufficiency. There is currently no universally-accepted threshold for cortisol levels that is used to diagnosis adrenal crisis; however, several studies have suggested that a serum cortisol concentration of less than 25 mcg/dL is an acceptable cut-off value for the diagnosis, and our patient met this criteria. Aside from this cortisol concentration, he also displayed several of the common clinical findings of adrenal crisis, which should have led to a more extensive work-up for this condition as well as immediate treatment.
Conclusions: Primary adrenal insufficiency, which may be caused by autoimmune disease, infection, or hemorrhage, is a potentially fatal condition that necessitates quick diagnosis so that the proper treatment may be administered. In a patient with adrenal insufficiency, cortisol levels within normal limits can be deceiving, and the diagnosis requires a high index of suspicion. Therefore, in a patient presenting with clinical features of adrenal crisis, it is important to promptly measure ACTH levels and perform a Cosyntropin test, without delaying treatment.