Cardiogenic Shock: An Initial Presentation of Primary Adrenal Insufficiency

ABSTRACT Objective: To describe a unique case of a young patient with undiagnosed primary adrenal insufficiency presenting with cardiogenic shock that promptly improved with the administration of stress-dose steroids. Methods: We present the clinical history, physical findings, laboratory results, and imaging studies of a young female presenting with cardiogenic shock. The association between adrenal insufficiency and cardiogenic shock and pertinent literature are reviewed. Results: A 19-year-old Caucasian female was found unresponsive at home. She had a history of a 30-kg weight loss over the past year, salt craving, and generalized hyperpigmentation. An echocardiogram showed severe dilation of the left ventricle and global hypokinesis. Despite hydration, vasopressors, extracorporeal membrane oxygenation, intra-aortic balloon pump placement, and empiric antibiotics, she remained hypotensive. Serum cortisol was undetectable. She was started on stress-dose steroids. Her blood pressure subsequently improved and she was weaned off inotropes, was extubated, and had an improvement of her cardiac function. Adrenal antibodies and 21-hydroxylase antibodies were both positive, suggesting that her adrenal insufficiency was autoimmune in nature. She ultimately made a full recovery. Conclusion: Due to nonspecific symptoms on presentation, primary adrenal insufficiency can be challenging to diagnose. Although the presentation of cardiogenic shock in a patient with undiagnosed adrenal insufficiency is considered a rarity, with hypovolemic shock being more common, practitioners should consider adrenal insufficiency in the differential diagnosis for cardiogenic shock and not delay the institution of stress-dose steroids. Abbreviations: CT = computed tomography CVP = central venous pressure GC = glucocorticoid LV = left ventricle