A Single Episode of Hypoglycemia as a Possible Early Warning Sign of Adrenal Insufficiency

Abstract A 65-year-old woman without a history of diabetes mellitus was admitted for elective total knee arthroplasty for osteoarthrosis. There were no specific complaints except for knee flexion contractures, and the results of preoperative tests were unremarkable. On the day of surgery, the patient suffered from a hypoglycemic attack (52 mg/dL) after preoperative overnight fasting. A dextrose infusion immediately corrected the hypoglycemia, and a total knee arthroplasty was then performed. Although a hypoglycemic attack did not recur, further evaluation was required because of nausea that persisted after surgery. The morning serum cortisol level was 0.15 µg/dL with undetectable adrenocorticotropic hormone (ACTH), and the insulin-like growth factor-1 level was 9 ng/mL. An empty sella and bilateral adrenal atrophy were evident in imaging studies. ACTH and growth hormone (GH) did not respond to testing with corticotropin-releasing hormone and GH–releasing peptide-2, respectively. While serum cortisol did not increase on a rapid ACTH stimulation test, urinary free cortisol excretion responded to a prolonged ACTH stimulation test. Finally, the patient was diagnosed as having empty sella syndrome with ACTH and GH deficiencies. After the administration of hydrocortisone as maintenance replacement therapy, the patient’s prolonged postoperative nausea disappeared. Adrenal insufficiency is latent in patients with hypoglycemia episodes. Because patients with adrenal insufficiency require appropriate perioperative corticosteroid supplementation, clinicians should give priority to identifying the underlying etiology of hypoglycemia over non-urgent elective surgery when these co-occur.

[1]  15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 , 2019, Diabetes Care.

[2]  M. Maghnie,et al.  Central adrenal insufficiency in children and adolescents. , 2018, Best practice & research. Clinical endocrinology & metabolism.

[3]  M. Mori,et al.  Usage of continuous glucose monitoring (CGM) for detecting an unrecognized hypoglycemia and management of glucocorticoid replacement therapy in adult patients with central hypoadrenalism. , 2018, Endocrine journal.

[4]  U. Steuerwald,et al.  Inborn Errors of Metabolism with Hypoglycemia: Glycogen Storage Diseases and Inherited Disorders of Gluconeogenesis. , 2018, Pediatric clinics of North America.

[5]  P. Zelissen,et al.  Adrenal Crisis: Still a Deadly Event in the 21st Century. , 2016, The American journal of medicine.

[6]  H. Slimane,et al.  Ramadan fasting in patients with adrenal insufficiency , 2016, Endocrine.

[7]  P. Clifton,et al.  Recurrent nocturnal hypoglycaemia as a cause of morning fatigue in treated Addison’s disease – favourable response to dietary management: a case report , 2015, BMC Endocrine Disorders.

[8]  S. Hahner,et al.  Diagnosis and management of adrenal insufficiency. , 2015, The lancet. Diabetes & endocrinology.

[9]  G. Chrousos,et al.  Adrenal insufficiency , 2014, The Lancet.

[10]  V. Tucci,et al.  The clinical manifestations, diagnosis, and treatment of adrenal emergencies. , 2014, Emergency medicine clinics of North America.

[11]  G. Pontrelli,et al.  Nocturnal hypoglycaemia in ACTH and GH deficient children: role of continuous glucose monitoring , 2013, Clinical endocrinology.

[12]  J. Deeks,et al.  Hypoglycemia in Non-Diabetic In-Patients: Clinical or Criminal? , 2012, PloS one.

[13]  K. Badenhoop,et al.  Nocturnal hypoglycemia identified by a continuous glucose monitoring system in patients with primary adrenal insufficiency (Addison's Disease). , 2012, Diabetes technology & therapeutics.

[14]  A. Anabtawi,et al.  Incidence of hypoglycemia with tight glycemic control protocols: a comparative study. , 2010, Diabetes technology & therapeutics.

[15]  S. Hahner,et al.  Delayed Diagnosis of Adrenal Insufficiency Is Common: A Cross-Sectional Study in 216 Patients , 2010, The American journal of the medical sciences.

[16]  Michael E. Matheny,et al.  Hypoglycemia and Clinical Outcomes in Patients With Diabetes Hospitalized in the General Ward , 2009, Diabetes Care.

[17]  P. Cryer,et al.  Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. , 2009, The Journal of clinical endocrinology and metabolism.

[18]  C. Gravholt,et al.  Effects of cortisol on carbohydrate, lipid, and protein metabolism: studies of acute cortisol withdrawal in adrenocortical failure. , 2007, The Journal of clinical endocrinology and metabolism.

[19]  M. Kocak,et al.  Clinical report of 28 patients with Sheehan's syndrome. , 2003, Endocrine journal.

[20]  K. Wood,et al.  Corticosteroid supplementation for adrenal insufficiency. , 2002, JAMA.

[21]  D. Swaab,et al.  Glucocorticoids suppress corticotropin-releasing hormone and vasopressin expression in human hypothalamic neurons. , 1998, The Journal of clinical endocrinology and metabolism.

[22]  R. Carey,et al.  Adrenal insufficiency. , 1997, Current therapy in endocrinology and metabolism.

[23]  W. Oelkers,et al.  Hyponatremia and inappropriate secretion of vasopressin (antidiuretic hormone) in patients with hypopituitarism. , 1989, The New England journal of medicine.