SUN-LB066 Assessing the Need for Individualized Sick Day Protocol in a Patient with Secondary Adrenal Insufficiency and Pneumonia

Introduction: Secondary Adrenal Insufficiency (SAI) has a prevalence of 280 per million [1]. Most patients with chronic SAI are on daily glucocorticoid replacement therapy. However, due to underlying inability to mount cortisol response to illness, it is critical to implement a Sick Day Protocol (SDP). We present the case of septic shock due to pneumonia, in a patient with secondary hypocortisolism following meningeal tumor resection. Case Presentation: A 60 year old Caucasian female presented to ED with fever and progressively worsening cough with purulent sputum for four days. She had hypertension, hypothyroidism, Type 2 diabetes, and secondary hypocortisolism following resection of meningotheliomatous meningioma. At presentation she was febrile and in septic shock with elevated WBC with left shift [14 (4.5 -11 K/microL)], lactic acid [7.2 (0.7-2.0 mmol/L)] and procalcitonin [41 (<0.5 ng/ml)]. Despite bolus IV fluids, stress dose steroids and broad-spectrum antibiotics, patient continued to be encephalopathic and hypotensive (MAP <65 mm Hg). She thus required pressor support (Norepinephrine) in ICU. Chest X-ray and CT confirmed pneumonia in left lower lobe and lingula. Home regimen of hydrocortisone comprised 17.5 mg at 0900 and 7.5 mg at 1700. Within 12 hours of stress dose hydrocortisone (250 mg) she was successfully weaned off norepinephrine with resolution of encephalopathy, and WBC normalized. She was given stress dose hydrocortisone (200 mg/day) for four days. She was then discharged home with instruction to finish oral course of antibiotics, continue home dosing of hydrocortisone and to further discuss SDP with primary healthcare provider. Discussion: In times of severe physiological stress, cortisol levels can raise up to tenfold normal levels. Cortisol plays key role in maintaining vascular integrity, potentiating vasoconstrictor effects of catecholamines and mediating anti-inflammatory effects on immune system [2]. Patients with chronic adrenal insufficiency require hydrocortisone dosing of 10-12 mg/m2 body surface area (15-25mg/day) in two doses with two-thirds of the dose optimally administered in AM to mimic physiological cycling [1]. This patient had symptoms of pneumonia for four days and had only been taking her regular hydrocortisone doses. This case emphasizes the need for individualized counselling for early SDP in patients with SAI. References: [1] Nicolaides NC, Chrousos GP, Charmandari E. Adrenal Insufficiency. [Updated 2017 Oct 14]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK279083/ [2] Jung, C., & Inder, W. (2008). Management of adrenal insufficiency during the stress of medical illness and surgery. Medical Journal Australia, 188(7), 409-413. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.