SHM Converge Scientific Abstract ePoster Gallery-Pain in the Pituitary: Story of Fever of Unknown Origin

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A 42-year-old woman with chronic pain, anxiety, depression, and substance use disorder was admitted for 6–7 months of recurrent low-grade fevers, weakness, weight loss, dizziness, nausea/vomiting, presyncope/syncope, blurred vision, and diffuse body pain. She had previously been evaluated for fever of unknown origin (FUO) with an extensive negative workup, except for candida esophagitis, and had left the hospital before completion of that evaluation.<br /><br />On readmission, she had documented fever, low-normal blood pressure, hypokalemia, microcytic anemia, and markedly elevated inflammatory markers, but no leukocytosis. Repeated infectious, rheumatologic, thrombotic, endocrine, and hematologic evaluations were unrevealing. This included multiple negative blood, urine, fungal, and TB cultures; HIV, syphilis, hepatitis testing; chest imaging; echocardiography; dental imaging; thyroid studies; and bone marrow biopsy. Because of persistent symptoms and a low cortisol level, adrenal insufficiency was suspected and confirmed with a cortisol stimulation test.<br /><br />She was started on steroids, after which her fevers and weakness improved significantly. After discharge, she reported marked improvement and return to work while taking steroids; when she ran out of medication, her symptoms recurred, further supporting the diagnosis.<br /><br />The authors conclude that adrenal insufficiency should be considered in the differential diagnosis of FUO, especially when the infectious workup is negative. In this case, the likely cause was opioid-induced adrenal insufficiency, due to chronic opioid use suppressing the hypothalamic-pituitary-adrenal axis. This rare but important diagnosis may be easily missed without awareness of its association with opioids.

Asset Subtitle

David P. Dorcius

Meta Tag

Author List David P. Dorcius, Kari L. Esbensen, Maria Jesusa De Guzman, Patricia R. Hwang

Category Clinical Vignettes

Concept Opioid-Induced Adrenal Insufficiency

Concept Adrenal Insufficiency

Concept Fever of Unknown Origin

Concept ACTH Stimulation Test

Concept Hypotension

Distinguished Non-Finalist

Presenter Organization Emory University School of Medicine

Presenting Author David P. Dorcius

Track Adult

Keywords

adrenal insufficiency

fever of unknown origin

opioid-induced adrenal insufficiency

chronic opioid use

cortisol stimulation test

hypothalamic-pituitary-adrenal axis

recurrent fever

weight loss

substance use disorder

steroid treatment

Opioid-Induced Adrenal Insufficiency

Adrenal Insufficiency

Fever of Unknown Origin

ACTH Stimulation Test

Hypotension