Progressive Fatigue and Adrenal Dysfunction Concerns in a 38-Year-Old Woman with Connective Tissue Disorder

Case at a Glance

A 38-year-old woman with hypermobile Ehlers-Danlos syndrome presents with progressive fatigue, hypotension, and suspected adrenal insufficiency affecting her work performance and daily functioning.

Patient's Story

The patient reports severe daytime fatigue that prevents her from being productive at work until 2-3 PM, regardless of wake time. She experiences constant lethargy, body weakness, and episodes where she nearly falls asleep at her desk despite adequate sleep duration (up to 12 hours). She has a history of adverse reaction to an inhaler years ago that caused blackouts, with subsequent research suggesting possible adrenal gland involvement. Currently experiencing what she describes as 'tiredness attacks' and uncontrollable yawning episodes that bring her to tears.

Initial Assessment

Patient presents with chronic hypotension (readings as low as 80/50 mmHg), orthostatic symptoms requiring careful position changes to prevent fainting, and suspected dehydration despite increased fluid intake. Recent laboratory work revealed significantly low B12 levels, elevated cholesterol, and abnormal cortisol patterns. Patient was recently started on an anti-candida diet and caffeine restriction.

The Diagnostic Journey

Given the constellation of symptoms including severe fatigue, hypotension, abnormal cortisol levels, and history of suspected adrenal-related medication reaction, the differential diagnosis includes primary or secondary adrenal insufficiency, particularly in the context of her underlying connective tissue disorder. The timing coincides with weaning off propranolol, which may be contributing to symptom exacerbation.

Final Diagnosis

Pending comprehensive endocrine evaluation scheduled within the week. Suspected adrenal insufficiency with possible perimenopause as contributing factor.

Treatment Plan

Patient advised to continue current medication regimen including gradual propranolol taper. Maintaining anti-candida diet and increased fluid intake for hypotension management. Comprehensive endocrine consultation scheduled to evaluate adrenal function and hormone levels.

Outcome and Follow-up

Patient counseled that current symptoms, while concerning, do not require emergent intervention and that waiting for scheduled appointment in 3 days is appropriate. No immediate life-threatening concerns identified. Follow-up planned post-endocrine consultation for treatment adjustment based on diagnostic findings.