(Kiosk 4) Rehabilitation of Severe Traumatic Brain Injury Complicated by Obtained Panhypopituitarism, Stress Dose Steroids Causing Central Diabetes Insipidus

Case Diagnosis: 25-year-old male with new severe traumatic brain injury (TBI), causing adrenal insufficiency (AI) and central diabetes insipidus (CDI).

Case Description: Patient had mental status fluctuations which coincided with sodium shifts, resulting in diagnosis of AI and CDI. 12 weeks after the accident he was discharged to acute rehabilitation (AR), at max assist with front wheel walker (FWW). He slowly improved over 6 weeks, until an episode of status epilepticus when his prednisone was increased to stress dosing. During this time, in less than 28 hours, his sodium increased from 145 to 158.

Discussion: After a TBI, AI can be seen in the setting of damage to the pituitary gland or severing of the pituitary stalk. This patient developed AI, requiring treatment with daily prednisone. However, stress secondary to infection or seizures, leading to need for prednisone stress dosing, would quickly change patient’s sodium levels, resulting in acute mental status changes. This led to multiple functional declines and grossly prolonged his rehabilitation course.

Setting: Academic Hospital

Assessment/Results: Patient’s mental status had declined to the point he was no longer participatory in therapies and needed a gastric-tube for nutrition. After 2 months of stabilization, he was transferred back to AR, where his sodium was monitored daily. 2 months later, he was minimum assist for safety and ambulation with FWW, and was able to speak in short sentences occasionally.

Conclusion: Patients with TBI and fluctuations in mental status should have labs checked and be treated for AI and CDI if discovered. Further, in a patient with known AI under stress, serial labs are necessary in treatment as prednisone can lead to the unmasking of CDI. Accurate diagnosis and treatment of CDI can then lead to increased function and decreased AR time for patients.