Case Report: Suspected perioperative adrenal crisis presenting as severe reversible quadriplegia after laparoscopic partial adrenalectomy

Adrenal crisis after unilateral partial adrenalectomy is rare. Severe generalized muscle weakness as the first and main manifestation is even less common, and it is easily mistaken for residual neuromuscular blockade. Patients whose adrenocortical reserve is reduced, for instance those with a low-normal morning cortisol who face a long operation, may carry the highest risk. A 53-year-old obese woman with hypertension, type 2 diabetes, and coronary artery disease underwent laparoscopic partial adrenal resection. Soon after surgery she developed flaccid quadriplegia, a relative drop in blood pressure, and nausea with vomiting. Imaging showed no acute intracranial or spinal lesion, and repeat reversal of neuromuscular blockade had no effect. Her strength returned in close temporal relation to high-dose methylprednisolone. Follow-up hormonal testing showed a blunted cortisol response to ACTH stimulation, consistent with suppression of the hypothalamic–pituitary–adrenal (HPA) axis, although ongoing glucocorticoid exposure confounded this result and the cause of the episode could not be settled. The picture fits a suspected perioperative adrenal crisis presenting as atypical severe weakness after adrenal surgery. Because quantitative neuromuscular monitoring was not used, a residual neuromuscular blocking component cannot be fully excluded. Still, when paralysis after adrenal surgery cannot be explained, clinicians should think of glucocorticoid deficiency early and give empirical glucocorticoids without waiting for laboratory results.