Abstract
Hyponatraemia is common in hospital practice, with the syndrome of inappropriate antidiuresis (SIAD) being the most common underlying aetiology. A relatively less frequent but important cause is adrenal insufficiency (AI). We describe the case of a 63-year-old man who presented with symptomatic hyponatraemia and hypoglycaemia associated with abnormal body movements (ballism). The recent commencement of levothyroxine for newly diagnosed hypothyroidism, followed by fluid restriction for presumed SIAD, led to the worsening of a previously undiagnosed AI. His investigations confirmed central AI in association with thyroid and growth hormone deficiencies. The underlying cause of hypopituitarism, in this case, was a traumatic brain injury He responded well to steroid replacement and fluids. This case highlights that SIAD remains a diagnosis of exclusion, and other causes of hyponatraemia, including AI, should always be considered. Second, levothyroxine treatment without steroid replacement can lead to an adrenal crisis in patients with underlying AI.