Unusual blood pressure response in a patient with secondary adrenocortical insufficiency

A patient with suspected exogenous hyperadrenocorticism and hypertension was treated with cessation of steroids, a low-sodium diet, and moderate doses of diuretics. Hypertension persisted, and severe dehydration and hyponatremia developed, but all responded to normal saline administered intravenously. The concurrence of (1) hypoadrenocorticism and its attendant fluid and electrolyte disturbances, (2) the use of diuretics, and (3) an intact renin-angiotensin system was responsible for the exaggerated and seemingly paradoxical responses. Selection of diuretics should be made cautiously and careful patient monitoring is imperative when compromised adrenocortical function is suspected.