SUN-446 A Twist of Fate: Unveiling Addison’s Disease in the Midst of a Binge Drinking Episode

Abstract Disclosure: Y. Abdullah: None. Addison’s disease, or primary adrenal insufficiency, is a rare yet potentially life-threatening disorder caused by the destruction or dysfunction of the adrenal cortex, leading to insufficient glucocorticoid and mineralocorticoid production. Early symptoms such as fatigue, anorexia, nausea, and abdominal pain are often subtle and nonspecific, delaying diagnosis. In acute settings, patients may develop severe hypoglycemia, hypotension, hyponatremia, and hyperkalemia, which can precipitate an adrenal crisis. Binge drinking can worsen such presentations by fueling hypoglycemia and metabolic derangements, obscuring other pathologies. While alcohol-induced metabolic encephalopathy commonly explains altered mental status in binge drinkers, adrenal insufficiency can produce similar features, including hypoglycemia-driven encephalopathy and cardiovascular compromise. Distinguishing these overlapping syndromes can be challenging, especially in adolescents lacking known comorbidities. We present an 18-year-old man who arrived with severe altered mental status after a binge drinking episode. He was profoundly hypoglycemic (blood glucose of 10 mg/dL) on admission, briefly improved with IV dextrose, yet repeated hypoglycemic episodes persisted. Further investigations showed mild hyponatremia, a baseline cortisol below 0.1 nmol/L, and a poor cortisol response to ACTH stimulation. Elevated plasma ACTH (∼122 pmol/L) and positive 21-hydroxylase antibodies confirmed primary adrenal insufficiency. MRI of the brain revealed no structural abnormality, and normal very long-chain fatty acid levels excluded adrenoleukodystrophy. The patient’s status improved significantly with glucocorticoid replacement, and he was discharged for endocrine follow-up. This case underscores the interplay between binge drinking, metabolic encephalopathy, and life-threatening hypoglycemia, highlighting the diagnostic challenge of “overshadowing,” where Addison’s disease may be overlooked in favor of an alcohol-related cause. We emphasize that adrenal insufficiency should be considered in younger, otherwise healthy individuals presenting with recurrent hypoglycemia, hyponatremia, or refractory shock. Early detection and targeted therapy remain critical to preventing adrenal crisis. Furthermore, the report illustrates how consistent use of a systematic diagnostic approach can unmask uncommon yet crucial etiologies in patients with severe metabolic derangements, ensuring that no presumed explanation prematurely ends the search for a treatable condition. Presentation: Sunday, July 13, 2025