Persistent Hypothermia and DeliriumRevealing Central AdrenalInsufficiency in Cirrhosis

Abstract

Central adrenal insufficiency is uncommon and difficult to diagnose in frail cirrhotic patients, as symptoms overlap with infection and metabolic disturbances. A 70-year-old man with Child-Pugh C10 cirrhosis and multicentric hepatocellular carcinoma (BCLC stage D) presented with persistent hypothermia (32 °C) and progressive hypoactive delirium despite broad-spectrum antibiotic therapy for left basal pneumonia. Cortisol levels were low with inappropriately low ACTH; brain CT was unremarkable. Low-dose prednisone (10 mg/day) led to rapid normalization of temperature and marked neurological improvement within 36 hours. Refractory hypothermia may represent an under-recognized clinical marker of adrenal insufficiency in cirrhosis. Clinical response to glucocorticoids may be diagnostically decisive.