Adrenal insufficiency with peritoneal caking in a young male: The role of granulomatous disease in a non-classic presentation: A case report

Background: Adrenal Insufficiency is an uncommon disease, presenting with relatively vague signs and symptoms making diagnosis highly challenging [1]. Generalized weakness, anorexia, fatigue, malaise, and weight loss are some examples of how a patient may present. We present a case of secondary adrenal insufficiency with evidence of peritoneal caking suggestive of, but unconfirmed as, granulomatous disease. Case presentation: A 31-year-old male presented complaining of a one-month history of nausea, fatigue, and loss of appetite. Clinical examinations revealed tachycardia, altered mental status, and signs of dehydration. Hyperpigmentation of the oral mucosa and lips was evident, in addition to abdominal striae. Laboratory evaluation revealed normal serum potassium (4.2 mmol/L), hypercalcemia (3.35 mmol/L), and hypercalciuria. A diagnosis of adrenal insufficiency was confirmed by the Short Synacthen Test (SST) result which revealed: Baseline cortisol: 336 nmol/L, 30 min: 374 nmol/L, 60 min: 362 nmol/L, AM ACTH: 21.3 pg/mL. Adrenal CT showed normal adrenal glands. Pan-CT revealed nodular peritoneal thickening with omental caking; however, peritoneal biopsy was negative for tuberculosis and malignancy. The patient started glucocorticoid replacement therapy and showed improvement on follow-up. Conclusion: Secondary adrenal insufficiency can present with rare and non-classic findings such as abnormal biochemical results and imaging features suggestive of infiltrative disease. This case highlights the importance of considering secondary and infiltrative causes in atypical presentations while acknowledging that definitive histological confirmation may not be obtained [2].