Case Report Adrenal insufficiency following bariatric surgery J. W. Stephens 1,2 , K. Boregowda 2 , J. Barry 1 , D. E. Price 2 , N. Eyre 1 and J. N. Baxter 1 1 Welsh Institute of Metabolic and Obesity Surgery, Morriston Hospital, ABM University Health Board, Swansea, Wales, UK; 2 Department of Diabetes and Endocrinology, ABM University Health Board, Swansea, Wales, UK Received 9 January 2012; revised 30 January 2012; accepted 31 January 2012 Summary A 35-year-old woman with morbid obesity and amenorrhoea underwent a bilo- pancreatic diversion (BPD). Surgery was successful with good weight loss, resto- ration of menstruation and almost immediately she conceived for the first time. She was commenced on routine vitamin supplements after surgery but failed to attend follow-up clinic. Five years later, she presented with limb girdle pains, lethargy, night blindness, skin pigmentation, amenorrhoea and dizziness. She had stopped taking supplements prescribed after the surgery. Investigations showed severe vitamin A and D deficiency along with iron and calcium deficiency. Her cholesterol was low at 3.5 mmol L -1 . Despite aggressive vitamin replacement, she continued to complain of lethargy and dizziness. Subsequently, three short adrenocorticotropic hormone-stimulation tests were suboptimal (basal cortisol: 196, 185 and 223 nmol L -1 ; 30 min cortisol: 421, 453 and 435 nmol L -1 ). She was subsequently commenced on adrenal replacement and her symptoms resolved and she conceived. We describe for the first time in the literature the unexpected finding of adrenal insufficiency following a BPD. Keywords: Adrenal insufficiency, bariatric surgery, cholesterol, cortisol, obesity, steroid. obesity reviews (2012) 13, 560–562 Malabsorptive bariatric surgery including bilo-pancreatic diversion (BPD) may be associated with nutritional defi- ciencies. We describe for the first time in the literature the unexpected finding of adrenal insufficiency following a BPD. Case report A 30-year-old woman (body mass index [BMI]: 54 kg m -2 ) who underwent an uneventful BPD was prescribed forceval, calcichew D3, vitamin B12, ferrous sulfate and multivita- mins. Surgery was successful and associated with the return of menstruation and she subsequently conceived for the first time. Following the birth of a healthy son, she was lost to follow-up. Five years (BMI: 36 kg m -2 ) later, she presented to her physician with left foot pain and proximal leg weak- ness. Ten months later, she was referred to the endocrine clinic. She also complained of lethargy, dizziness, night blindness, generalized skin pigmentation and amenorrhoea. She had stopped taking ferritin, vitamin D, multivitamins and forceval from 6 months post-partum. Investigations showed: haemoglobin: 9.6 g dL -1 ; ferritin: 9 ng mL -1 (13– 150); vitamin B12: 464 pg mL -1 (191–663); folate: 16.8 ng mL -1 (4.6–18.7); corrected calcium: 2.05 mmol L -1 ; parathyroid hormone: 25.9 pmol L -1 (1.6–6.8); vitamin D: < 5 ng mL -1 (10–50); vitamin A: 0.1 mmol L -1 (1.10– 2.60); total cholesterol: 3.5 mmol L -1 ; and low-density lipoprotein (LDL) cholesterol: 1.4 mmol L -1 . Vitamin C, vitamin E, zinc, copper, gonadotrophins and oestradiol were normal. She was restarted on calcichew D3 forte (three tablets twice a day containing calcium 500 mg and chole- calciferol 400 U) and vitamin A + D combined supplements (six tablets twice a day of 4,000/400 U) and ferrous sulfate, vitamin B6 and forceval. Within 6 months, the foot pain and night blindness improved. There was a partial improvement in the obesity reviews doi: 10.1111/j.1467-789X.2012.00987.x 560 © 2012 The Authors obesity reviews © 2012 International Association for the Study of Obesity 13, 560–562, June 2012