{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T05:21:08Z","timestamp":1788240068368,"version":"build-2803163510"},"reference-count":16,"publisher":"American Academy of Pediatrics (AAP)","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,1]]},"abstract":"<jats:p>Primary adrenal insufficiency, or Addison disease, can be caused by an autoimmune process and presents with poor growth, poor weight gain, nausea, vomiting, fatigue, and skin hyperpigmentation. During times of stress or illness, patients with untreated or insufficiently treated adrenal insufficiency are at risk for adrenal crisis progressing to hypotensive shock, lethargy, confusion, coma, and death. While primary adrenal insufficiency is reported as a rare cause of encephalopathy, and more rarely encephalitis in adults, it is not known to be associated with encephalitis in children. Here, we present a unique case of a female 17-year-old who presented with significant encephalopathy and magnetic resonance imaging findings consistent with acute leukoencephalopathy with restricted diffusion and who was ultimately found to be in adrenal crisis secondary to influenza-related encephalitis. Due to rapidly declining neurologic function and concern for infectious encephalitis, the new diagnosis of adrenal insufficiency was not initially identified. Less common electrolyte derangements, including hypercalcemia and hyperphosphatemia, also contributed to difficulties in diagnosis. After initiation of steroid replacement, the patient progressed to make remarkable functional progress. This case underscores the importance of navigating diagnostic uncertainty in complex pediatric care to improve patient outcomes. In addition, this case contributes to the growing literature of primary adrenal insufficiency in the pediatric patient and demonstrates the important role of glucocorticoids on neurologic function and calcium\/phosphate metabolism.<\/jats:p>","DOI":"10.1542\/peds.2025-072983","type":"journal-article","created":{"date-parts":[[2026,4,22]],"date-time":"2026-04-22T00:03:01Z","timestamp":1776816181000},"source":"Crossref","is-referenced-by-count":0,"title":["Unmasking Adrenal Insufficiency: Adrenal Crisis Triggered by Influenza-Associated Encephalitis"],"prefix":"10.1542","volume":"157","author":[{"given":"Natalie","family":"Segev","sequence":"first","affiliation":[{"name":"1Division of Endocrinology, Cincinnati Children\u2019s Hospital Medical Center, Cincinnati, Ohio"},{"name":"2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Wilson","sequence":"additional","affiliation":[{"name":"2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio"},{"name":"3Division of Neurology, Cincinnati Children\u2019s Hospital Medical Center, Cincinnati, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Molly","family":"Moehlman","sequence":"additional","affiliation":[{"name":"2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio"},{"name":"3Division of Neurology, Cincinnati Children\u2019s Hospital Medical Center, Cincinnati, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah D.","family":"Corathers","sequence":"additional","affiliation":[{"name":"1Division of Endocrinology, Cincinnati Children\u2019s Hospital Medical Center, Cincinnati, Ohio"},{"name":"2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio"},{"name":"4James M. Anderson Center of Health Systems Excellence, Cincinnati Children\u2019s Hospital Medical Center, Cincinnati, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"417","published-online":{"date-parts":[[2026,4,22]]},"reference":[{"issue":"2","key":"2026090101115061600_r1","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1210\/jc.2015-1710","article-title":"Diagnosis and treatment of primary adrenal insufficiency: an Endocrine Society clinical practice guideline","volume":"101","author":"Bornstein","year":"2016","journal-title":"J Clin Endocrinol Metab."},{"issue":"3","key":"2026090101115061600_r2","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1210\/clinem\/dgaa881","article-title":"Primary adrenal insufficiency in childhood: data from a large nationwide cohort","volume":"106","author":"Capalbo","year":"2021","journal-title":"J Clin Endocrinol Metab."},{"issue":"11","key":"2026090101115061600_r3","doi-asserted-by":"crossref","first-page":"596","DOI":"10.1111\/j.1440-1754.2004.00482.x","article-title":"Primary adrenal insufficiency in childhood and adolescence: advances in diagnosis and management","volume":"40","author":"Simm","year":"2004","journal-title":"J Paediatr Child Health."},{"key":"2026090101115061600_r4","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.ejpn.2021.05.017","article-title":"The spectrum of acute leukoencephalopathy with restricted diffusion (ALERD): a case series and review of literature","volume":"33","author":"Lawrence","year":"2021","journal-title":"Eur J Paediatr Neurol."},{"issue":"4","key":"2026090101115061600_r5","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1176\/jnp.2006.18.4.450","article-title":"The neuropsychiatric profile of Addison\u2019s disease: revisiting a forgotten phenomenon","volume":"18","author":"Anglin","year":"2006","journal-title":"J Neuropsychiatry Clin Neurosci."},{"issue":"4","key":"2026090101115061600_r6","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1097\/NRL.0000000000000374","article-title":"Adrenal crisis presenting as recurrent encephalopathy mimicking autoimmune, infectious encephalitis, and common variable immune deficiency: a case report","volume":"27","author":"Poon","year":"2022","journal-title":"Neurologist."},{"issue":"1","key":"2026090101115061600_r7","doi-asserted-by":"crossref","first-page":"119","DOI":"10.2169\/internalmedicine.3234-19","article-title":"Cognitive impairment caused by isolated adrenocorticotropic hormone deficiency without other hypo-adrenalism signs - autoimmune encephalopathy mimics","volume":"59","author":"Matsuo","year":"2020","journal-title":"Intern Med."},{"issue":"1\u20132","key":"2026090101115061600_r8","first-page":"173","article-title":"Severe hypothalamopituitary dysfunction accompanied by influenza-associated encephalopathy: report of two pediatric cases","volume":"26","author":"Yagasaki","year":"2013","journal-title":"J Pediatr Endocrinol Metab."},{"issue":"6","key":"2026090101115061600_r9","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1111\/j.1365-2796.1992.tb00636.x","article-title":"Hypercalcaemia in Addison\u2019s disease: calciotropic hormone profile and bone histology","volume":"232","author":"Montoli","year":"1992","journal-title":"J Intern Med."},{"issue":"6","key":"2026090101115061600_r10","doi-asserted-by":"crossref","first-page":"523","DOI":"10.1007\/BF02411297","article-title":"Etiology of hypercalcemia in a patient with Addison\u2019s disease","volume":"34","author":"Muls","year":"1982","journal-title":"Calcif Tissue Int."},{"issue":"5","key":"2026090101115061600_r11","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1210\/er.2018-00097","article-title":"Glucocorticoids and bone: consequences of endogenous and exogenous excess and replacement therapy","volume":"39","author":"Hardy","year":"2018","journal-title":"Endocr Rev."},{"issue":"7","key":"2026090101115061600_r12","doi-asserted-by":"crossref","first-page":"561","DOI":"10.2169\/internalmedicine.41.561","article-title":"Isolated adrenocorticotropin deficiency presenting with impaired renin-angiotensin-aldosterone system and suppressed parathyroid hormone-vitamin D axis","volume":"41","author":"Saito","year":"2002","journal-title":"Intern Med."},{"issue":"Suppl 3","key":"2026090101115061600_r13","doi-asserted-by":"crossref","first-page":"e2020045948D","DOI":"10.1542\/peds.2020-045948D","article-title":"Diagnostic error in pediatrics: a narrative review","volume":"149","author":"Marshall","year":"2022","journal-title":"Pediatrics."},{"issue":"1","key":"2026090101115061600_r14","doi-asserted-by":"crossref","first-page":"e2144531","DOI":"10.1001\/jamanetworkopen.2021.44531","article-title":"Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study","volume":"5","author":"Schiff","year":"2022","journal-title":"JAMA Netw Open."},{"issue":"8","key":"2026090101115061600_r15","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1097\/ACM.0000000000003153","article-title":"Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis","volume":"95","author":"Mamede","year":"2020","journal-title":"Acad Med."},{"issue":"2","key":"2026090101115061600_r16","doi-asserted-by":"crossref","first-page":"e484","DOI":"10.1542\/peds.2006-1612","article-title":"Adrenal insufficiency: still a cause of morbidity and death in childhood","volume":"119","author":"Shulman","year":"2007","journal-title":"Pediatrics."}],"container-title":["Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/publications.aap.org\/pediatrics\/article-pdf\/doi\/10.1542\/peds.2025-072983\/1927366\/pediatrics.2025072983.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/publications.aap.org\/pediatrics\/article-pdf\/doi\/10.1542\/peds.2025-072983\/1927366\/pediatrics.2025072983.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T05:11:58Z","timestamp":1788239518000},"score":1,"resource":{"primary":{"URL":"https:\/\/publications.aap.org\/pediatrics\/article\/157\/5\/e2025072983\/207227\/Unmasking-Adrenal-Insufficiency-Adrenal-Crisis"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,22]]},"references-count":16,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,4,22]]},"published-print":{"date-parts":[[2026,5,1]]}},"URL":"https:\/\/doi.org\/10.1542\/peds.2025-072983","relation":{},"ISSN":["0031-4005","1098-4275"],"issn-type":[{"value":"0031-4005","type":"print"},{"value":"1098-4275","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,22]]},"article-number":"e2025072983"}}