Abstract
BACKGROUND: Adrenal insufficiency is a potentially life-threatening condition that often presents with nonspecific symptoms. While fatigue, hypotension, and electrolyte disturbances are common features, seizures and stress-induced cardiomyopathy are rare initial manifestations. This case is reported for its atypical presentation and to highlight the diagnostic challenge it posed in the absence of classic biochemical findings. CASE PRESENTATION: We report a case of a 68-year-old Hispanic woman with diabetes, hypertension, dyslipidemia, and hypopituitarism secondary to Sheehan syndrome, who presented with new-onset seizures after abruptly discontinuing chronic steroid therapy. Her symptoms included progressive weakness and behavioral changes over several weeks. Initial evaluation revealed hyperglycemia, mild hyponatremia, and no hyperkalemia-findings consistent with secondary adrenal insufficiency-associated seizures, although contributing to initial diagnostic uncertainty. Brain imaging incidentally identified a developmental cerebral venous anomaly, which was initially suspected as a potential cause of the seizures. In addition, echocardiographic findings were consistent with Takotsubo cardiomyopathy, likely precipitated by the stress of her medical condition. However, further evaluation confirmed adrenal insufficiency with low cortisol and adrenocorticotropic hormone levels, and subnormal response to cosyntropin stimulation. Management included hydrocortisone for adrenal insufficiency and levetiracetam for seizure prophylaxis, leading to symptom resolution and no recurrence of seizures. CONCLUSION: This case emphasizes the importance of maintaining a high index of suspicion for adrenal insufficiency in patients with a suggestive history, even when classic electrolyte abnormalities are absent and neuroimaging reveals confounding findings. Recognizing rare presentations such as seizures and stress cardiomyopathy can prevent delays in diagnosis and improve outcomes.