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An unusual presentation of primary adrenal insufficiency with new onset type 1 diabetes: case report and review of the literature

Shelby Graf ORCID logo, Rachel Stork Poeppelman, Jennifer McVean, Arpana Rayannavar and Muna Sunni



To describe an atypical presentation of primary adrenal insufficiency in conjunction with new onset type 1 diabetes.

Case presentation

Here, we describe a case of new-onset type 1 diabetes (T1D) presenting simultaneously with an unusual presentation of primary adrenal insufficiency in a previously healthy 16-year-old. He was admitted for a typical presentation of diabetic ketoacidosis, but with extreme hyponatremia. An extensive workup revealed a low aldosterone level, appropriate cortisol level, and positive 21-hydroxylase antibodies. While the phenomenon of multiple autoimmune conditions developing in the same patient is well-described, this particular case has several atypical aspects. Our patient’s case highlights the danger of relying on random serum cortisol in the setting of acute illness to rule out adrenal insufficiency.


Adrenal insufficiency can present as isolated hypoaldosteronism without hypocortisolemia and can manifest as severe hyponatremia in the context of diabetic ketoacidosis. Workup for an unusual presentation of T1D should include a 21-hydroxylase antibody, as well as thyroid and celiac disease studies.

Corresponding author: Shelby Graf, MD, PGY-3, University of Minnesota Pediatrics, 2450 Riverside Ave., Room M136, 1st Floor, East Building, Minneapolis, MN 55454, USA, Phone: +952 250 4369, Fax: +612 626 7042, E-mail:

Jennifer McVean, Consults for Medtronic and is on an advisory board for Mannkind.

  1. Research funding: None declared.

  2. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  3. Competing interests: Authors state no conflict of interest. The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: The research related to human use has been complied with all the relevant national regulations, institutional policies, and in accordance with the tenets of the Helsinki Declaration.


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Received: 2021-03-17
Accepted: 2021-10-25
Published Online: 2021-11-24

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