SAT-447 Subacute Adrenalitis identified by CT imaging

Abstract Disclosure: S.S. Mathew: None. B. Cunningham: None. H. Qadeer: None. Subacute adrenalitis is a condition causing a gradual onset of adrenal insufficiency. Symptoms remain similar to conditions such as Addison’s, the chronic form of adrenal insufficiency, and can include hypotension, hypothermia, hypoglycemia. The time course for symptoms of subacute adrenalitis is what separates it from other conditions: it is less acute than adrenal crisis, but more rapid than Addison's disease. If not treated appropriately early on, this condition can progress to an acute adrenal crisis. A 24-year-old male with a past medical history significant for autism spectrum disorder and intellectual disability presented to the ED for lethargy, poor oral intake, hypothermia, hypoglycemia, and hypotension requiring intensive care. Labs showed high-normal sodium and potassium. Random cortisol prior to administration of exogenous steroid was 5.1 mcg/dL, with an elevated ACTH. 21 hydroxylase antibody was negative, TSH was mildly elevated but with normal free T4. CT abdomen showed bilateral adrenal glands with central low attenuation, similar to necrosis, and thin rim peripheral enhancement, suspicious for subacute adrenalitis. Patient was given 100 mg IV hydrocortisone, with rapid improvement in the clinical picture. Fludrocortisone was initially held as electrolytes were within normal limits. Later in the hospital course, it was trialed for persistent lethargy; ultimately the lethargy improved and fludrocortisone was able to be discontinued, as well as hydrocortisone down-titrated. Patient was eventually able to be discharged on physiologic hydrocortisone dosing, 15 mg AM and 5 mg PM, with stress dose instructions. Our patient presented symptoms typical of adrenal insufficiency, including hypotension, hypothermia and hypoglycemia. Given the acute nature of the presentation, he was treated appropriately as an adrenal crisis. Per family reports, however, the timeline of his symptoms began at least four days prior to admission, fitting more into the category of a subacute adrenalitis. This diagnosis is often missed due to the timing of symptoms but early recognition can prevent onset of acute adrenal crisis. CT imaging can help diagnose the difference between Addison’s and subacute adrenalitis, with the former showing general atrophy of adrenal glands, and the latter showing peripheral rim enhancement. Once an established diagnosis is made, treatment can be tailored appropriately.It is important to recognize the timeframe for adrenal insufficiency symptoms, as there may be opportunities to prevent life-threatening crises. Acute, subacute, and chronic adrenal insufficiency all require treatment with steroids to replenish adrenal activity. Ensuring the correct diagnosis with labs and imaging at the onset of signs or symptoms is essential to ensuring best patient care. Presentation: Saturday, July 12, 2025