Two contrasting cases of adrenal insufficiency in adults: a case report

BACKGROUND: Adrenal insufficiency (AI) is a clinical syndrome characterized by insufficient secretion of glucocorticoids and/or mineralocorticoids. The incidence of AI is low, and its clinical manifestations are non-specific, including fatigue, generalized weakness, nausea, and weight loss. Consequently, the condition can easily be misdiagnosed or overlooked. If not treated promptly, it may progress to a life-threatening adrenal crisis. This paper reports one case of primary and one case of secondary adrenal insufficiency, aiming to enhance clinical vigilance regarding this disease through a comparative case analysis. CASE PRESENTATION: Both patients were of East Asian descent, comprising a 67-year-old female and an 80-year-old male. They were hospitalized with long-standing histories of recurrent, unexplained electrolyte disturbances, anorexia, nausea, and vomiting. Subsequent investigations revealed the following: in Patient 1, the serum cortisol level was markedly decreased, while the adrenocorticotropic hormone (ACTH) level was compensatorily elevated to an extreme degree. Combined with imaging studies that identified bilateral adrenal calcifications, a diagnosis of primary adrenal insufficiency (potentially triggered by tuberculosis) was ultimately established. In contrast, Patient 2 was found to have significantly low levels of both serum cortisol and ACTH. A pituitary magnetic resonance imaging (MRI) demonstrated a sellar mass, leading to a diagnosis of secondary adrenal insufficiency. Following the initiation of glucocorticoid replacement therapy, the clinical symptoms and electrolyte abnormalities in both patients improved rapidly. Long-term follow-up indicated a favorable prognosis. CONCLUSION: These cases aim to highlight that adrenal insufficiency should be considered in the differential diagnosis for patients presenting with non-specific symptoms such as nausea, vomiting, fatigue, hypotension, or refractory electrolyte imbalances. Relevant diagnostic tests should be promptly completed to establish the etiology and initiate treatment as early as possible.