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

Figures & data

Table 1 Preoperative Blood Tests

	Values	Units	References
WBC	5,500	/µL	(4,000-8,000)
Neutrophils	51.7	%	(40-70)
Eosinophils	5.3	%	(0-5)
Hemoglobin	12.7	g/dL	(12-15)
Platelets	194,000	/µL	(150,000-350,000)
Total bilirubin	0.33	mg/dL	(0.3-1.2)
AST	21	U/L	(8-38)
ALT	9	U/L	(4-44)
LDH	182	U/L	(106-220)
ALP	223	U/L	(117-335)
G-GT	15	U/L	(12-73)
CPK	96	U/L	(40-182)
BUN	18.2	mg/dL	(8-19)
Creatinine	0.63	mg/dL	(0.5-0.9)
Sodium	139	mEq/L	(136-148)
Potassium	4.3	mEq/L	(3.6-5.0)
Chloride	105	mEq/L	(98-109)
Calcium	9.3	mg/dL	(8.8-10.8)
Albumin	3.9	g/dL	(3.8-5.3)
Glucose	90	mg/dL	(70-110)
HbA1c	6	%	(4.7-6.2)
TSH	7.22	µIU/mL	(0.34-3.8)
FT3	2.15	pg/mL	(2-3.8)
FT4	0.99	ng/dL	(0.8-1.5)

Note: Reference ranges are shown in parentheses in the far right column.

Abbreviations: ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; CPK, creatine phosphokinase; FT3, free triiodothyronine; FT4, free thyroxine; G-GT, gamma glutamyl transferase; HbA1c, glycated hemoglobin; LDH, lactate dehydrogenase; TSH, thyroid-stimulating hormone; WBC, white blood cells.

Table 2 Hormones Measured on the Morning of Fasting

	Values	Units	References
ACTH	<1.5	pg/mL	(7.2-63.3)
Cortisol	0.15	µg/dL	(6.24-18.0)
TSH	5.75	µIU/mL	(0.34-3.8)
FT3	2.14	pg/mL	(2-3.8)
FT4	1.01	ng/dL	(0.8-1.5)
PRL	10.5	ng/mL	(3.12-15.3)
LH	12.3	mIU/mL	(5.72-64.31)
FSH	30.6	mIU/mL	(<157.79)
Estradiol	<5.0	pg/mL	(<47.0)
Progesterone	<0.05	ng/mL	(<0.33)
GH	0.82	ng/mL	(0.13-9.88)
IGF-1	9	ng/mL	(64-188)
Aldosterone	101	pg/mL	(29.9-159)
PRA	0.5	ng/mL/hr	(0.3-2.9)
DHEAS	<2	µg/dL	(12-133)

Note: Reference ranges are shown in parentheses in the far right column.

Abbreviations: ACTH, adrenocorticotropic hormone; DHEA-S, dehydroepiandrosterone sulfate; FT3, free triiodothyronine; FT4, free thyroxine; FSH, follicle-stimulating hormone; GH, growth hormone; IGF-1, insulin-like growth factor-1; LH, luteinizing hormone; NM, not measured; PRA, plasma renin activity; PRL, prolactin; TSH, thyroid-stimulating hormone.

Figure 1 75 g oral glucose tolerance test Horizontal axes indicate time courses. Vertical axes indicate levels of glucose (circles, solid line) and IRI levels (triangles, dotted line).

Abbreviation: IRI, immunoreactive insulin.

Figure 2 Magnetic resonance imaging of the pituitary. T1-weighted magnetic resonance images, without contrast, are shown. Left, Sagittal plane. Right, coronal plane. Yellow arrows indicate an empty sella.

Figure 3 Abdominal computed tomography. Horizontal computed tomography images, without contrast, are shown. Yellow arrows indicate right and left atrophic adrenal glands.

Figure 4 Pituitary stimulation tests. (A) Corticotropin-releasing hormone test. ACTH, circles and solid line. Cortisol, triangles and dotted line. (B) Thyrotropin-releasing hormone test. TSH, circles and solid line. PRL, triangles and dotted line. (C) Gonadotropin-releasing hormone test. LH, circles and solid line. FSH, triangles and dotted line. (D) Growth hormone-releasing peptide-2. GH, circles and solid line. Horizontal axes indicate time courses. Vertical axes indicate hormone levels.

Abbreviations: ACTH, adrenocorticotropic hormone; FSH, follicle-stimulating hormone; GH, growth hormone; LH, luteinizing hormone; PRL, prolactin; TSH, thyroid-stimulating hormone.

Figure 5 ACTH stimulation tests. (A) Conventional dose rapid ACTH stimulation test using 250 µg synacthen. Circles and a solid line represent the serum cortisol level. (B) Prolonged ACTH stimulation test using 0.5 mg tetracosactide twice daily. Vertical gray columns represent UFC. Horizontal axes indicate time courses. Vertical axes indicate values.

Abbreviations: ACTH, adrenocorticotropic hormone; UFC, urinary free cortisol.