Bypassing the Adrenals: A Rare Case of Adrenal Insufficiency Following Bariatric Surgery

Background: Adrenal insufficiency (AI) is a life-threatening disorder that is generally caused by primary adrenal failure or by hypothalamic-pituitary impairment of the corticotropic axis. Patients often present with fatigue, hypotension, anorexia, and weight loss. There are few reported cases of AI following bariatric surgery; a type of procedure designed to cause weight loss and anorexia - two of the cardinal symptoms of AI. Establishing a diagnosis of AI in patients who have undergone bariatric surgery can be challenging due to symptom overlap, but it is of critical importance given that an acute stressor has the potential to precipitate adrenal crisis with risk of death. Clinical Case: A 42-year-old woman presented 15-months after sleeve gastrectomy with biliopancreatic diversion and duodenal switch with nausea, vomiting, decreased oral intake, weight loss, weakness and fatigue. Her symptoms were severe, requiring admission to the hospital and were initially thought to be a result of her bariatric surgery. Initial intake exam and labs were notable for mild hypotension, persistent hypoglycemia with hemoglobin A1c <3.4%. Further evaluation revealed a low AM cortisol (5.5 μg/dL) and diagnosis of AI was confirmed by a failed cosyntropin stimulation test with cortisol levels of 7.0 μg/dL and 10.6 μg/dL 30- and 60-minutes after cosyntropin administration, respectively. Her diagnosis remained confounded by the presence of concomitant micronutrient deficiencies including copper, zinc, vitamin D and vitamin B6. Furthermore, she was found to have low insulin and c-peptide levels of 1 μU/mL and 0.4 ng/ml, respectively, despite persistent hypoglycemia. The patient was treated with enteral nutrition via nasojejunal feeds and glucocorticoid replacement therapy with daily oral hydrocortisone and fludrocortisone. Each of her symptoms improved after initiation of steroid replacement therapy and she was discharged home. Conclusion: Clinicians should keep a high degree of suspicion for adrenal insufficiency in patients who have undergone bariatric surgery due to the degree of symptom overlap in this population.