Can adrenal insufficiency cause hypothermia?

Adrenal Insufficiency and Hypothermia

Yes, adrenal insufficiency can cause decreased body temperature (hypothermia), particularly during an adrenal crisis. This is an important clinical manifestation that should be recognized as a potential sign of adrenal insufficiency requiring urgent intervention.

Pathophysiology of Hypothermia in Adrenal Insufficiency

• Cortisol plays a key role in glucose homeostasis and thermoregulation 1
• Inadequate cortisol levels impair counter-regulatory mechanisms that maintain normal body temperature
• Hypothermia can be a presenting feature of adrenal crisis, alongside other symptoms 2

Clinical Presentation of Adrenal Insufficiency with Hypothermia

Hypothermia in adrenal insufficiency often occurs alongside other symptoms:

• Temperature below 36°C (can be as low as 35.1°C even in warm environments) 3
• Hypotension (often requiring fluid resuscitation or vasopressors) 2
• Hypoglycemia (particularly in neonates and children) 1
• Hyponatremia and hyperkalemia (more common in primary adrenal insufficiency) 4
• Fatigue, weakness, anorexia, and vomiting 3

Types of Adrenal Insufficiency Associated with Hypothermia

1. Primary Adrenal Insufficiency:

   • Direct impairment of adrenal gland function
   • Presents with both cortisol and aldosterone deficiency
   • More severe electrolyte abnormalities (↓Na, ↑K)
   • Higher risk of adrenal crisis 2

2. Secondary/Tertiary Adrenal Insufficiency:

   • Due to pituitary or hypothalamic dysfunction
   • Cortisol deficiency with preserved aldosterone
   • Generally normal electrolytes
   • Still at risk for hypothermia during stress 4

Risk Factors for Hypothermia in Adrenal Insufficiency

• Older age 5
• More extensive physiological stress (such as larger burn surface area in burn patients) 5
• Comorbidities, particularly asthma and diabetes 2
• Mineralocorticoid or vasopressin dependency 2
• Interruption of physiological replacement therapy 2

Diagnostic Considerations

• ACTH stimulation tests may be misleading in hypothermic patients and should be performed only after body temperature has normalized 6
• Cortisol response to ACTH is depressed in hypothermic patients, with minimal responses observed below 32°C 6
• Paradoxical surges in ACTH and cortisol can occur after glucocorticoid replacement in central adrenal insufficiency 3

Management of Hypothermia in Adrenal Insufficiency

For patients with suspected adrenal crisis presenting with hypothermia:

1. Immediate intervention:

   • Hydrocortisone 100 mg IV immediately 2
   • Fluid resuscitation with normal saline (10-20 ml/kg; maximum 1,000 ml) 2
   • Active warming measures

2. Continued management:

   • Hydrocortisone infusion of 200 mg/24h until stabilized 2
   • Monitor for improvement in temperature, blood pressure, and other symptoms
   • Consider adrenal insufficiency in patients with vasopressor-resistant hypotension 2

3. Recovery phase:

   • Double the regular oral replacement dose of hydrocortisone for 48h up to a week following resolution of acute illness 2
   • Resume maintenance dose once fully recovered

Important Clinical Considerations

• Hypothermia can be an early warning sign of impending adrenal crisis
• Temperature <38°C in a patient with known adrenal insufficiency should prompt evaluation for inadequate glucocorticoid replacement 2
• Mortality is significantly higher in patients who develop adrenal insufficiency during critical illness (59.1% vs 14.6% in controls) 5
• ACTH-independent cortisol secretion may function as a stress response during cold exposure, but is insufficient to prevent hypothermia in adrenal insufficiency 7

Early recognition of hypothermia as a sign of adrenal insufficiency is crucial for preventing potentially fatal adrenal crisis and improving patient outcomes.