Secondary adrenal insufficiency (SAI) had been diagnosed in a nondiabetic lady with recurrent hypoglycemia having low morning cortisol and low-normal adrenocorticotropic hormone. Her symptoms persisted despite being on supplemental hydrocortisone. Appropriate workup subsequently documented endogenous hyperinsulinemia. Solitary pancreatic endocrine tumor, primary hyperparathyroidism due to multiglandular pathology, and the presence of multiple collagenomas established the diagnosis of multiple endocrine neoplasia type 1 (MEN1) syndrome. Basal morning cortisol (1.9 µg/dL) was grossly suppressed in this lady, and so was the cortisol value (2.2 µg/dL) measured during hypoglycemia (plasma glucose: 24 mg/dL). Recurrent hypoglycemia due to any cause, results in a functional abnormality of the hypothalamus–pituitary–adrenal (HPA) axis in individuals without primary disease of the HPA pathway. The defect may be severe enough to lower the basal and stimulated cortisol values much below the established cut-offs for adrenal insufficiency, and patients may be misdiagnosed to have adrenal failure. Complete normalization of cortisol values are observed following strict avoidance of hypoglycemia.
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