Saved by the Pickles

Document Type

Conference Proceeding

Publication Date

8-2026

Abstract

Initial History/Presentation: A 17-year-old female presents with progressive weight loss, nausea, vomiting, abdominal pain, and weakness over eight months, during which she underwent multiple evaluations and her symptoms were attributed to anxiety due to psychosocial stressors. In a recent admission, she was found to be malnourished and underwent gastrointestinal evaluation, which revealed celiac disease. She was also diagnosed with avoidant/restrictive food intake disorder (ARFID) and discharged after meeting caloric goals. Several weeks after discharge, admission was requested by Gastroenterology for nasogastric tube placement and nutritional supplementation due to ongoing weight loss.

Physical Exam: She appeared thin and fatigued. Vital signs were notable for orthostatic hypotension, and she demonstrated generalized weakness on examination. During discussion, her father mentioned that she “loved pickles” and frequently drank the juice, reflecting a strong preference for salty foods. This prompted a more deliberate reassessment of her physical exam, at which time she was noted to appear tanner than her father, with hyperpigmented palmar creases on closer inspection.

Diagnostic Evaluation: Laboratory evaluation included a complete blood count and comprehensive metabolic panel. Electrolyte studies revealed hyponatremia, hypochloremia, normal potassium, and mild hypercalcemia. Prior admissions had also documented recurrent hyponatremia. Given the constellation of signs and symptoms, an 8 AM serum cortisol and adrenocorticotropic hormone (ACTH) levels were obtained.

Diagnosis: Endocrinology was consulted after morning studies revealed an undetectable cortisol with markedly elevated ACTH (>2000 pg/mL), confirming primary adrenal insufficiency. She was initiated on stress-dose intravenous hydrocortisone followed by transition to maintenance glucocorticoid and mineralocorticoid replacement therapy.

Discussion/Conclusion: This case underscores premature diagnostic closure in an adolescent whose presentation appeared consistent with an eating disorder. Despite diagnoses of celiac disease and ARFID, persistent orthostasis, salt craving, hyperpigmentation, and electrolyte abnormalities suggested an alternative unifying diagnosis. The association between autoimmune adrenal insufficiency and celiac disease reinforces the need to maintain a broad differential when symptoms persist. Her rapid improvement after hormone replacement highlights how avoiding anchoring bias in adolescents is essential to identifying treatable, life-threatening conditions.

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Pediatric Hospital Medicine Conference, August 6-9, 2026, Kansas City, MO

Helen DeVos Children's Hospital

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