SAT-419 A Hypoglycemic Crisis: Insulinoma or Adrenal Insufficiency?

Abstract Disclosure: M. Nassiri: None. T. Prasad: None. J.D. Packer: None. Introduction: Adrenal insufficiency is a condition in which the body’s ability to produce hormones aimed at responding to stressful conditions is impaired. Cortisol is the main stress hormone produced by the adrenal glands to respond to stress, and functions to regulate blood pressure, metabolism, inflammation, and blood glucose. A very serious complication of adrenal insufficiency known as “adrenal crisis” can arise and become life-threatening if not treated imminently. Case Presentation: A male in his 80s with a medical history of hypertension, hypothyroidism, and BPH presented to the emergency department due to an unwitnessed ground level fall and acute altered mental status. The patient’s family had noticed he had mild confusion and appeared disoriented. Vitals were remarkable for hypertension. While having his blood drawn, the patient became unresponsive with generalized weakness and was unable to follow commands. Fingerstick blood sugar was low at 35, and he received IV dextrose 50% with improvement in blood sugars to 124. An hour and a half later, his blood sugar dropped again to less than 10. Despite receiving continuous dextrose fluids, the patient continued with hypoglycemic events and was admitted to the ICU. Stroke workup and CT imaging were unrevealing. MRI abdomen identified multiple pancreatic cysts, largest one in the pancreatic body measured 8 x 9 mm and in the head of the pancreas measured 9 x 18 mm, likely representing intraductal papillary mucinous neoplasms (IPMNs). Lab studies revealed normal beta hydroxybutyrate, proinsulin, insulin-like growth factor 1, IGF binding protein 2, insulin antibody, CEA, random cortisol, am cortisol, ACTH, TSH, and T4. C-peptide was low and hemoglobin A1c was 4.8. CRP was elevated and fasting insulin was 155. The patient did not have a history of diabetes, nor was he taking insulin medications at home. Of note, the patient had undergone a recent knee replacement a few weeks earlier, but upon evaluation by Orthopedic surgery, there was no clinical evidence of infection or concern for septic arthritis. He received stress dose steroids, however, despite continuous dextrose infusions the patient continued with persistent hypoglycemia. Discussion: This case demonstrates a unique presentation in the diagnostic challenges and delays in effective management of adrenal crises in the setting of normal cortisol. It’s important to consider the body has a much higher than usual requirement for cortisol during times of injury, physical ailments, and surgery. While the patient was noted to have IPMNs, approximately 70-80% are benign and do not cause any symptoms. In the case of our patient, it is likely he was in a state of adrenal crisis secondary to post operative surgical stress, despite his cortisol levels being normal. In these circumstances, early suspicion and prompt treatment of adrenal insufficiency is of utmost importance to prevent fatal outcomes. Presentation: Saturday, July 12, 2025