Disclosures: Weston T. Northam, MD: Nothing to disclose

Case Description: A 49-year-old female athlete presented 7 weeks after she struck her head while sparring with a karate partner. Her symptoms included right-sided headache, difficulty maintaining visual focus, dizziness/nausea, and fatigue. Her past medical history included allergies/asthma for which she took intranasal fluticasone. She endorsed intermittent clear fluid draining from her right ear when leaning forward for 6 days following the impact and had persistent polydipsia and polyuria. She denied fever/chills, facial weakness, or hearing loss. The patient had a history of two prior concussions from which she recovered quickly but was now suffering from persistent symptoms. The vital signs were unremarkable. Her physical examination was remarkable for severe nausea and visual strain with extraocular muscle testing. A basic metabolic panel was ordered, along with a pituitary function panel and cranial imaging.

Setting: Clinic

Patient: 49-year-old woman

Assessment/Results: A preliminary diagnosis was made of adrenal insufficiency (AI) / hypopituitarism with low serum cortisol, hypernatremia and complaints of worsening headache, nausea/vomiting, and inability to sustain fluid intake. A subsequent cosyntropin stimulation test revealed AI. MRI brain and CT temporal bones were normal.

Discussion: Existing literature suggests patients can suffer from neuroendocrine dysfunction following traumatic brain injury. In our patient cosyntropin stimulation did not adequately increase the serum cortisol levels. Therefore, we felt that the patient had chronic subclinical adrenal suppression secondary to long term use of inhaled fluticasone. Her secondary AI was likely unmasked by traumatic hypopituitarism from the concussion.

Conclusion: This case demonstrates a complicated presentation with multiple coinciding neuroendocrine conditions. It is important to consider endocrine dysfunction in patients who sustain concussion with lingering symptoms, especially in the context of chronic corticosteroid use. Comprehensive care of concussed athletes includes detecting chronic repercussions from hypopituitarism.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/karate-related-concussion-preceding-adrenal-insufficiency-and-hypopituitarism-a-case-report/