7705 Paliperidone Induced Central Adrenal Insufficiency: A Case Report

Abstract Disclosure: I. Shevtsova: None. Introduction: Atypical antipsychotics reduce ACTH and control secretion in healthy subjects. However, the clinical significance of it is still unclear with only a few case reports tying antipsychotics to clinically relevant adrenal insufficiency. Case: A 32-year-old male with schizoaffective and polysubstance abuse disorders was admitted to a hospital with a complex right hand infection complicated by MRSA bacteremia, and native mitral and tricuspid valves infective endocarditis. To control the source of infection, the patient underwent multiple surgical interventions and the bacterial endocarditis required a prolonged course of IV antibiotics. The patient’s mental health negatively affected his hospital course. He was diagnosed with a schizoaffective disorder several years ago, and his mental disease has been difficult to control. There were multiple ED visits and hospitalizations for mental health issues due to significant positive and negative symptoms, substance abuse and medication noncompliance. For the last several months, the patient had not taken his medication (paliperidone). Initially, the patient displayed impulsive, aggressive, and irrational behavior caused by substance withdrawal and uncontrolled mental health illness. Paliperidone was restarted with great clinical response within 5-6 days. On week 2, the patient developed prominent symptomatic hypotension, extreme fatigue, and sleepiness. The repeat blood count was within normal limits, and chemistry showed normal electrolyte levels. Transesophageal echocardiography showed resolution of vegetation, normal ventricles and valves functions. Morning cortisol level was low, 1.58 ug/dl (3.2-22.4 ug/dl) with significant increase to 23.07 ug/dl after cosyntropin stimulation. ACTT level was inappropriately borderline low, 7.8pg/ml (7.2-63 pg/ml) and 21 hydroxylase antibodies were negative. Considering all the findings, a confident clinical diagnosis of central adrenal insufficiency was made. MRI of pituitary gland did not reveal any pathology. Drug induced central adrenal inefficiency became a primary working diagnosis. Paliperidone was discontinued. After 2 days, there was improvement in vital signs and other symptoms of adrenal insufficiency. This established a potential association between adrenal insufficiency and paliperidone. Unfortunately, the patient became restless and agitated again after withholding paliperidone for 5 days, so it was resumed. Adrenal insufficiency was treated with hormonal replacement therapy. Conclusion: This is the first case demonstrating possible paliperidone induced central adrenal insufficiency. It is important to note that even relative adrenal insufficiency caused by atypical antipsychotic might be life-threatening in a high stress state, such as sepsis. This needs to be recognized in a timely manner and managed appropriately. Presentation: 6/2/2024