PRIMARY ADRENAL INSUFFICIENCY FOLLOWING TRAUMATIC BRAIN INJURY - A CASE-REPORT AND REVIEW OF THE LITERATURE

Primary adrenal insufficiency (PAI) is a relatively rare but serious c ondition that can lead to signs and symptoms ranging from mild general ized weakness and fatigue to fulminant shock and death. We present the case of a previously healthy 31-year-old man who developed PAI while undergoing rehabilitation after a severe traumatic brain injury (TBI). The patient suffered a TBI with comminuted skull fractures, bifrontal contusions, and bilateral epidural hematomas in a jet-ski accident. A cute hospitalization was prolonged by several medical complications, a nd the patient was admitted for subacute rehabilitation 1 month after his injury with cognitive deficits, persistent agitation, confusion, g eneralized weakness, and poor endurance for therapy. His weakness, fat igue, and orthostasis did not improve with attempts at gradual remobil ization. The patient also had persistent anorexia, nausea, and hyponat remia despite various treatment regimens. Endocrinology workup showed normal anterior pituitary function but an abnormal response to adrenoc orticotropic hormone (ACTH) stimulation, leading to the diagnosis of P AI. The patient was treated with prednisone and fludrocortisone, which resulted in improvement in clinical symptoms followed by rapid gains in all functional areas. No previous descriptions of PAI following hea d injury were found in the medical literature. It is important for phy siatrists to be aware of this entity because symptoms of adrenal insuf ficiency can be similar to those commonly seen with TBI alone. PAI may also be confused with other endocrine disorders more frequently seen after TBI such as the syndrome of inappropriate antidiuretic hormone s ecretion. Recognition and appropriate management of adrenal insufficie ncy can lead to significant clinical and functional gains. (C) 1997 by the American Congress of Rehabilitation Medicine and the American Aca demy of Physical Medicine and Rehabilitation.