Adrenal insufficiency misdiagnosed as diabetic gastroparesis

Abstract

Persistent chronic vomiting in patients with diabetes is frequently assumed to be a consequence of diabetic gastroparesis (DG). However, other potentially treatable causes can produce the same clinical manifestations. We describe the case of a patient who presented with chronic vomiting without established cause, which was misdiagnosed as DG. A 32-year-old Caucasian woman was hospitalized due to a new episode of chronic nausea and vomiting. She was assessed in March 2016 by the Endocrinology Department of the Hospital Universitario La Paz, Madrid, Spain. She had a medical history of type 1 diabetes diagnosed at the age of 3, with multiple chronic microvascular and macrovascular complications. Menstrual cycles occasionally presented as polymenoreic. No previous pregnancies were reported. Other clinical records were as follows: exsmoker, dyslipidemia, overweight grade 2, oscillating subclinical hypothyroidism, iron deficiency anemia, and borderline personality disorder. Fourteen months prior to admission to the Hospital, she suffered hypoxic-ischemic encephalopathy due to attempted self-injury, which caused mild, acquired cognitive-functional deficit. Over the last 12 months, she presented with progressively decreased appetite, nausea, vomiting, abdominal pain, asthenia, and weight loss, and had a tendency to become hypoglycemic as well as experiencing difficulties determining the correct insulin doses to prevent hypoglycemia. During this period, she was admitted eight times to our hospital due to persistent vomiting. One month before the current episode, scintigraphy, showing delayed gastric emptying, led to a diagnosis of DG, with other possible structural, infectious, and inflammatory gastrointestinal causes being ruled out. Since multiple prokinetic drugs and diet regimens were tested with no successful results, a jejunostomy was scheduled. In the setting of the recent episode, the clinical examination revealed a weight of 84 kg, height of 177 cm, and body-mass index of 26.8 kg/m. She was lethargic with markedly asthenic facies. She presented proximal muscle weakness of the four extremities, pallor of palmar creases, and scarce hair in the armpits and genital area. She was on the second day of her menstrual cycle. Hormonal analyses performed in fasting blood samples obtained at 8 a.m. are displayed in Table 1. The Insulin-hypoglycemia test (IHT) for GH deficiency was not performed because her parents did not give their consent. There was no history of previous use of glucocorticoids (inhaled or oral) or other drugs such as progesterone or opioids. Pituitary autoantibodies were negative and magnetic resonance imaging of the sellar region revealed a 3 mm lesion suggestive of a cystic microadenoma. Based on the results, the patient was diagnosed as having central adrenal insufficiency (AI). The AI was attributed to the hypoxic-ischemic event in her history, which coincided with the onset of the aforementioned symptoms. Initiation of hydrocortisone therapy immediately improved the clinical picture. Oral tolerance was adequate from the third day and strength was recovered on the fifth day of the glucocorticoid therapy. Given the patient’s good progress, the jejunostomy was canceled and she was discharged. Eighteen months later, the patient’s isolated central AI persisted (Table 1). The patient has not been admitted to our hospital again since her discharge 4 years ago. To our knowledge, this is the second case to report AI as the putative cause of “pseudo-DG.” DG is defined as a delay in the emptying of ingested food in the absence of mechanical * Jorge Gabriel Ruiz-Sánchez [email protected]