Acute Adrenal Crisis

Adrenal crisis is acute life-threatening insufficiency of cortisol with or without aldosterone, occurring in patients with primary adrenal insufficiency (Addison disease, autoimmune adrenalitis, infection, hemorrhage, infiltration), secondary insufficiency from pituitary/hypothalamic disease, tertiary suppression from chronic glucocorticoid therapy, or as new presentation of undiagnosed adrenal disease.

Common precipitants are infection (gastroenteritis, sepsis, urinary tract infection), surgery, trauma, severe physical or emotional stress, sudden withdrawal of glucocorticoid therapy, and missed steroid replacement during illness. Patients in primary insufficiency may present with hyperpigmentation while secondary patients lack this finding. Mortality reaches 6-9% per crisis episode.

Clinical features are nonspecific and easily missed: hypotension refractory to fluids and vasopressors, dehydration, severe abdominal pain mimicking acute abdomen, fever, nausea, vomiting, hyponatremia, hyperkalemia (primary), hypoglycemia, eosinophilia, and altered mental status. Random cortisol <5 mcg/dL is suggestive; ACTH stimulation test confirms but should not delay treatment. Emergency management is empiric IV hydrocortisone 100 mg bolus then 50-100 mg every 6 hours or continuous infusion 200 mg/24 h, aggressive isotonic saline (1-3 L in first hour), dextrose for hypoglycemia, and treatment of precipitating cause. Patient education with steroid stress dose plan and emergency injection kit prevents future crises.