Search
hypoadrenal (Addisonian) crisis; acute adrenal insufficiency
Hypoadrenal (Addisonian) crisis occurs secondary inadequate release of glucocorticoids & mineralocorticoids from the adrenal cortex.
Etiology:
1) acute adrenal hemorrhage
2) precipitating factors in patient's with Addison's disease
a) infection, especially gastroenteritis with vomiting, diarrhea, dehydration
b) injury
c) surgery
d) less commonly
- exercise & emotional upset less frequently
- minor medical procedures such as vaccinations or infusions
- immunotherapy or chemotherapy
3) abrupt discontinuation of glucocorticoid therapy
4) risk factors
- older age
- history of prior adrenal crises [2]
- autoimmune polyglandular syndromes
- type 1 diabetes mellitus
- asthma
- cardiac disease [2]
Clinical manifestations:
- hypotension, shock
- acute abdominal symptoms
- delirium, obtundation, or both
- hyponatremia, hyperkalemia, hypoglycemia
- pyrexia
- some patients may have multiple episodes [2]
Laboratory:
1) chem 7
a) serum Na+: hyponatremia
b) serum K+: hyperkalemia
c) serum Cl- allows calculation of anion gap
d) serum bicarbonate: low due to metabolic acidosis
e) serum glucose: hypoglycemia
2) serum cortisol
3) eosinophil count may be elevated (eosinophilia)
Management:
1) volume expansion with intravenous saline
2) hydrocortisone 100 mg IV every 8 hours
- marked resolution of hypotension within 1 hour
- improvement in clinical symptoms within 2 hours [2]
3) parenteral administration of hydrocortisone at home may prevent progression of an early adrenal crisis [2]
- subcutaneous administration of hydrocortisone is an alternative to intramuscular injection (off-label) [2]
General
hypovolemic shock
Addison's disease (primary adrenal failure)
References
- Manual of Medical Therapeutics, 28th ed, Ewald &
McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 137, 474
- Rothaus C
Adrenal Crisis
NEJM Resident 360. Aug 28, 2019.
https://resident360.nejm.org/clinical-pearls/adrenal-crisis