A 65-year-old woman without a history of
diabetes mellitus was admitted for elective
total knee arthroplasty for
osteoarthrosis. There were no specific complaints except for knee flexion
contractures, and the results of preoperative tests were unremarkable. On the day of surgery, the patient suffered from a
hypoglycemic attack (52 mg/dL) after preoperative overnight fasting. A
dextrose infusion immediately corrected the
hypoglycemia, and a
total knee arthroplasty was then performed. Although a
hypoglycemic attack did not recur, further evaluation was required because of
nausea that persisted after surgery. The morning serum
cortisol level was 0.15 µg/dL with undetectable
adrenocorticotropic hormone (
ACTH), and the
insulin-like growth factor-1 level was 9 ng/mL. An empty sella and bilateral adrenal
atrophy were evident in imaging studies.
ACTH and
growth hormone (GH) did not respond to testing with
corticotropin-releasing hormone and GH-releasing peptide-2, respectively. While serum
cortisol did not increase on a rapid
ACTH stimulation test, urinary free
cortisol excretion responded to a prolonged
ACTH stimulation test. Finally, the patient was diagnosed as having
empty sella syndrome with
ACTH and GH deficiencies. After the administration of
hydrocortisone as maintenance replacement
therapy, the patient's prolonged
postoperative nausea disappeared.
Adrenal insufficiency is latent in patients with
hypoglycemia episodes. Because patients with
adrenal insufficiency require appropriate perioperative
corticosteroid supplementation, clinicians should give priority to identifying the underlying etiology of
hypoglycemia over non-urgent elective surgery when these co-occur.