Adrenal crisis presented as acute onset of hypercalcemia and hyponatremia triggered by acute pyelonephritis in a patient with partial hypopituitarism and pre-dialysis chronic kidney disease
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A 57-year-old woman with pre-dialysis chronic kidney disease (CKD) was hospitalized because of fever and fatigue. On admission, increased inflammatory response and pyuria with bacteriuria were observed. Pyelonephritis was successfully treated with antibiotics, whereas her fatigue continued and she developed progressive hypercalcemia and hyponatremia; serum sodium level, 116 mEq/L and corrected serum calcium level, 13.4 mg/dL. Plasma concentrations of adrenocorticotropic hormone and cortisol and serum luteinizing hormone were under the detection level. Although the reaction of other anterior pituitary hormones and the serum antidiuretic hormone (ADH) was preserved, the response of serum luteinizing hormone to administration of luteinizing hormone releasing hormone was impaired. Magnetic resonance imaging showed no structural abnormality in the thalamus, hypothalamus, and pituitary gland. She was diagnosed with adrenal insufficiency caused by partial hypopituitarism in concomitant with pyelonephritis. After starting hydrocortisone replacement, serum levels of sodium and calcium were rapidly normalized. This case highlights the importance of adrenal insufficiency as a differential diagnosis of hypercalcemia in patients with pre-dialysis CKD, especially when hyponatremia was concomitantly observed. Besides, infection should be considered as an important trigger for the development of latent adrenal insufficiency since it could increase the physiological demand of corticosteroid in the body. Also, CKD may enhance the magnitude of hypercalcemia since CKD patients have decreased capacity to increase urinary calcium excretion.
KeywordsAdrenal insufficiency Chronic kidney disease Hypercalcemia Hyponatremia Partial hypopituitarism
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Conflict of interest
All the authors declare no competing interest.
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This article does not contain any studies with human participants or animals performed by any of the authors.
A written informed consent was obtained from the patient included in this case study.
- 1.Assadi F. Hypercalcemia: an evidence-based approach to clinical cases. UJKD. 2009;3:71–9.Google Scholar
- 3.Ziegler R. Hypercalcemic crisis. J Am Soc Nephrol. 2001;12(Suppl 17):3–9.Google Scholar
- 6.Lunn MR, Muñoz Mendoza J, Pasche LJ, Norton JA, Ayco AL, Chertow GM. Hyperparathyroidism with hypercalcaemia in chronic kidney disease: primary or tertiary? NDT Plus. 2010;3:366–71.Google Scholar
- 7.Yamada S, Tsujikawa H, Eriguchi M, Taniguchi M, Tsuruya K. Hypercalcemia and large abdominal mass. NDT Plus. 2011;4:213–4.Google Scholar
- 13.Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ. The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study. Clin Endocrinol (Oxf). 2016;85:836–44.CrossRefGoogle Scholar