SHM Converge Scientific Abstract ePoster Gallery-Shock and H-P-Awe: An Acute Presentation of Opioid Induced Adrenal Insufficiency

Pdf Summary

A 19-year-old woman with a history of idiopathic thrombocytopenic purpura and opioid use disorder presented with 2 days of abdominal pain, fever, chills, malaise, confusion, and shock. She was hypotensive, tachycardic, tachypneic, febrile, pale, and later disclosed recent relapse with IV opioid use. She was admitted to the ICU for presumed septic shock and treated with broad-spectrum antibiotics, vasopressors, and stress-dose hydrocortisone.<br /><br />Extensive evaluation for infection and other causes was unrevealing: blood and urine cultures were negative, CT imaging of the chest/abdomen/pelvis was normal, and transthoracic/transesophageal echocardiography showed no endocarditis. On hospital day 4, she developed worsening lethargy, profound bradycardia, and hypothermia. Workup showed mild hypoglycemia, normal thyroid studies, and a low morning cortisol with inappropriately low ACTH, supporting secondary adrenal insufficiency. She improved dramatically after glucocorticoid replacement.<br /><br />The final diagnosis was opioid-induced adrenal insufficiency (OIAI), likely precipitated by transient bacteremia or another acute stressor in the setting of chronic opioid exposure. Her symptoms recurred when steroids were weaned, further supporting adrenal crisis. She was discharged after improvement, resumed buprenorphine/naloxone, and was counseled on physiologic steroid replacement, sick-day precautions, and tapering opioids.<br /><br />Key teaching points: chronic opioid agonist use can suppress the hypothalamic-pituitary-adrenal axis and cause secondary adrenal insufficiency; patients with opioid use disorder may present with overlapping septic and adrenal shock; and OIAI is underrecognized, despite being seen in an estimated 8%–29% of patients on chronic opioids.

Asset Subtitle

Claire Sevov

Meta Tag

Author List Claire Sevov, Phillip Ribbeck, Rich Dowd

Category Clinical Vignettes

Concept Opioid-Induced Adrenal Insufficiency

Concept Adrenal Crisis

Concept Hypotension

Concept Cortisol

Concept ACTH

Distinguished Non-Finalist

Presenter Organization The Ohio State University College of Medicine

Presenting Author Claire Sevov

Track Adult

Keywords

opioid-induced adrenal insufficiency

secondary adrenal insufficiency

adrenal crisis

opioid use disorder

septic shock

hypotension

hypothermia

hypoglycemia

hypothalamic-pituitary-adrenal axis

glucocorticoid replacement

Opioid-Induced Adrenal Insufficiency

Adrenal Crisis

Hypotension

Cortisol

ACTH