Updated: 12/10/2021

Adrenal Crisis

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  • Snapshot
    • A 26-year-old woman is brought to the emergency room after collapsing at her workplace. Per her coworker, the patient caught a cold yesterday and was complaining of a headache all day. The coworker mentions that she stopped taking her medication for her rheumatoid arthritis because of this. Her temperature is 103°F (39.4°C), blood pressure is 86/54 mmHg, pulse is 124/min, and respirations are 12/min. A physical examination demonstrates an unconscious patient with a positive Brudzinski sign. (Infection-induced adrenal crisis)
  • Introduction
    • Clinical definition
      • acute, life-threatening medical emergency characterized by the loss of adrenal function (e.g., low levels of cortisol)
  • Epidemiology
    • Demographics
      • most commonly occur in patients with primary adrenal insufficiency due to the characteristic volume depletion and hypotension resulting mainly from mineralocorticoid deficiency
    • Risk factors
      • primary adrenal insufficiency
      • chronic glucocorticoid use
  • ETIOLOGY
    • Pathogenesis
      • there is always an acute stressor or cause of adrenal insufficiency in patients with adrenal crisis
      • chronic primary adrenal insufficiency
        • occurs in patients with serious infection or other major stress (e.g., surgery)
      • glucocorticoid and/or mineralocorticoid insufficient dosing
        • may occur in patients with known primary/secondary adrenal insufficiency
        • can be due to
          • insufficient doses
          • failure to take more glucocorticoid during infection or major illness
          • persistent vomiting/diarrhea leading to decreased absorption
      • acute glucocorticoid withdrawal
        • includes oral and inhaled medications
        • occurs in patients who are abruptly withdrawn from glucocorticoid therapy
      • acute adrenal gland destruction
        • bilateral hemorrhage (e.g., Waterhouse-Friderichsen syndrome associated with meningococcemia)
        • bilateral infarction (e.g., heparin-induced thrombocytopenia)
        • trauma
      • acute causes of secondary/tertiary adrenal insufficiency
        • pituitary infarctions
  • Presentation
    • Symptoms
      • fever
      • abdominal or flank pain
      • anorexia, nausea, or vomiting
      • confusion or disorientation
      • severe lethargy
      • syncope
    • Physical exam
      • skin and mucosal hyperpigmentation (if Addison disease)
      • hypotension or shock
  • imaging
    • Computed tomography (CT)
      • may demonstrate bilateral adrenal injury, hemorrhage, or infarction
  • Studies
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is based on clinical presentation and confirmed (following initial treatment) with an endocrine evaluation
      • studies
        • serum cortisol concentration (e.g., morning serum cortisol)
          • best initial test
          • low serum cortisol (e.g., < 5 ug/dL) strongly suggests adrenal insufficiency
        • plasma ACTH concentration and stimulation test
          • indicated following initial treatment for differentiating the cause of adrenal insufficiency
          • levels will vary depending on the type of adrenal insufficiency
        • plasma aldosterone and renin levels
          • will have low aldosterone levels, renin levels will vary depending on the cause
        • chemistry panel
          • hyperkalemia
          • hyponatremia
  • Differential
    • Sepsis
      • distinguishing factors
        • will not have the significant electrolyte imbalances seen in adrenal crisis
  • Treatment
    • Treatment of patients should not be delayed while diagnostic tests are performed
    • First-line
      • IV fluids
        • volume replacement as patients are hypovolemic
        • 1-3L of 0.9% saline or 5% dextrose in 0.9% saline within the first 12-24 hours
      • glucocorticoid replacement
        • e.g., dexamethasone or hydrocortisone
        • to give initial bolus, then maintenance dose of 50 mg every 8 hours
      • mineralocorticoid replacement
        • not indicated in the acute setting as its effects take several days
        • in patients with known primary adrenal insufficiency or significant hyperkalemia, hydrocortisone can be given for its mineralocorticoid activity
  • Complications
    • Coma
    • Death

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