Diagnosing hypocortisolism in disguise: clinical insights from delayed-onset endocrine disorders

Background: Adrenal insufficiency is characterized by inadequate cortisol production, with or without aldosterone and adrenal androgen precursor deficiencies. This can make it difficult for the body to respond to stress and maintain essential functions. The symptoms of adrenal insufficiency are often non-specific, leading to delayed diagnosis and frequent misinterpretation. Case illustration: We report three cases of adrenal insufficiency: (1) a 61-year-old male with autoimmune polyendocrine syndrome II (cortisol 4.76 μg/dl baseline →10.6/12.2 post-adrenocorticotropic hormone; thyroid-stimulating hormone 369 IU/ml); (2) a 55-year-old female with secondary adrenal insufficiency due to partial empty sella syndrome (free T4 0.03 ng/dl; luteinizing hormone/follicle-stimulating hormone/prolactin ↓91–97%; and (3) a 37-year-old male with adrenal tuberculosis (bilateral enlargement on CT). In all the cases, the diagnosis is established through clinical evaluation and imaging followed by effective management with hormone replacement therapy. Conclusion: Atypical presentations of adrenal insufficiency require a high degree of clinical suspicion to ensure timely diagnosis and effective management.