Journal Article

SAT-451 Iatrogenic Adrenal Insufficiency Masquerading as Refractory Shock

Vaishnavi Kattamuri, Lakshmi Prasanna, Rajachandran, Manu S, Desai, Rohan, Duvvuru, Sparsha Reddy

2025

Overview

Abstract Disclosure: L. Kattamuri: None. S. Duvvuru: None. R. Desai: None. M. Rajachandran: None. Background: Chronic suppression of the HPA axis due to prolonged use of exogenous steroids can blunt the physiological glucocorticoid response when abruptly discontinued during periods of illness or stress. This can lead to tertiary adrenal insufficiency (TAI), which may present as unexplained vasopressor-resistant shock in critical care patients. Clinical Case: 50-year-old female with a history of breast cancer, diabetes, hypertension, and chronic joint pain was admitted for debridement of left submandibular abscess. Her hospital course was complicated by a right upper extremity DVT recanalized with catheter-directed thrombolysis and balloon angioplasty, and by persistent hypotension with mean arterial pressure (MAP) of 40-50mmHg, refractory to standard fluid resuscitation and vasopressor therapy (epinephrine, norepinephrine and vasopressin). Patient was empirically treated with broad-spectrum antibiotics for possible septic shock though blood bacterial and fungal cultures were sterile. No signs of hemorrhagic shock were noted. Transthoracic echocardiogram revealed ejection fraction of 65-70%, inferior vena cava and tricuspid jet velocity (226.5 cm/sec) were normal. Right heart catheterization (RHC) to assess the etiology of the hypotension was offered but declined by the family. Further history from family members revealed that the patient had been taking “Ardosons,” an over-the-counter pill from Mexico containing indomethacin, methocarbamol and 0.75 mg of betamethasone, twice daily for several years. While indomethacin use was documented, the Betamethasone component was not previously known. She received treatment with intravenous glucocorticoids for TAI with improvement in MAP (65-70 mmHg). Despite achieving hemodynamic stability with minimal vasopressor support, she developed progressive multi-organ failure. The patient subsequently expired after the family withdrew supportive care. Conclusion: This case demonstrates the critical value of a detailed history in patient care. Careful review of the patient’s medications was of inestimable importance in this case. Physicians should have a low threshold for diagnosis of TAI in critically ill patients with vasopressor-resistant unexplained hypotension. RHC, which was declined in this case, may have been of value for the evaluation and optimization of hemodynamics, identifying the precise etiology of the hypotension and guiding therapy in this critically ill patient. Presentation: Saturday, July 12, 2025

• Publisher: Oxford University Press
• Subject: Hypotension