A Case of Undifferentiated Shock Due to Probable Voriconazole-Related Primary Adrenal Insufficiency

Adrenal insufficiency (AI) can be a rare effect with azole antifungals, classically, ketoconazole. Whether AI can be observed with newer triazole drugs used for treating invasive fungal infections is far less understood. A 65-year-old man taking voriconazole for Aspergillus pneumonia was admitted to the intensive care unit with confusion and shock. He had hyperkalemia, hyponatremia, and refractory hypotension that resolved with high-dose prednisone for gout and withdrawal of voriconazole. He was discharged with a regimen of isavuconazole and 1 week later was found again with a morning cortisol level of 63.48 nmol/L (reference range, 165.60–507.84 nmol/L] and electrolyte derangements, along with symptoms of AI. His symptoms fully resolved with steroid and mineralocorticoid replacement.