A Diagnostic Challenge in the Emergency Department: Acute Intermittent Porphyria Unmasked After Cabergoline Exposure

Acute intermittent porphyria is a rare metabolic disorder that often presents with recurrent abdominal pain and nonspecific gastrointestinal symptoms, frequently leading to diagnostic delays in emergency settings. We report the case of a 24-year-old woman with glucose-6-phosphate dehydrogenase deficiency diagnosed at birth and pituitary prolactinoma treated with cabergoline 0.5 mg twice weekly, initiated one month before symptom onset, who presented with recurrent severe epigastric pain and vomiting over the course of one year. Repeated laboratory investigations and contrast-enhanced computed tomography of the abdomen and pelvis were unremarkable, and symptoms required opioid analgesia during multiple emergency department visits. A subsequent metabolic evaluation revealed elevated urinary porphyrin precursors, confirming acute intermittent porphyria. Following diagnosis, the cabergoline dose was reduced to 0.25 mg twice weekly with close monitoring of prolactin levels. During two years of follow-up, she experienced two recurrent attacks that were successfully managed with 2 L of 10% dextrose administered intravenously over three hours, along with opioid analgesia. This case highlights the importance of considering acute intermittent porphyria in patients with recurrent unexplained abdominal pain and emphasizes the possible role of medication-related and endocrine factors as indirect triggers, particularly in resource-limited settings where definitive therapy may not be available.