What are the symptoms and treatment of an adrenal crisis?

Adrenal Crisis: Symptoms and Treatment

Adrenal crisis presents with fever, chills, sweats, hypothermia, and hypotension, requiring immediate treatment with 100 mg IV hydrocortisone followed by fluid resuscitation and ongoing steroid therapy. 1

Clinical Presentation

Adrenal crisis is a life-threatening medical emergency that requires prompt recognition and treatment. Symptoms include:

• Cardiovascular manifestations:

  • Hypotension (often severe)
  • Tachycardia
  • Signs of shock

• Gastrointestinal symptoms:

  • Nausea and vomiting
  • Abdominal pain
  • Diarrhea

• Neurological symptoms:

  • Altered mental status
  • Confusion
  • Lethargy

• Other manifestations:

  • Fever, chills, sweats (or paradoxically hypothermia)
  • Weakness and fatigue
  • Dehydration

Differential Diagnosis: Primary vs Secondary Adrenal Insufficiency

Type	ACTH Level	Cortisol Level	Electrolytes	Hyperpigmentation
Primary	High	Low	↓Na, ↑K	Present
Secondary	Low	Low	Generally normal	Absent

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Treatment Algorithm

1. Immediate Management (First Hour)

• Administer hydrocortisone:

  • 100 mg IV bolus immediately 1, 2
  • Do not wait for laboratory confirmation before initiating treatment

• Fluid resuscitation:

  • Normal saline (0.9% NaCl) 10-20 ml/kg (maximum 1,000 ml) in the first hour 1
  • Address hypoglycemia if present

2. Ongoing Management

• Continue hydrocortisone:

  • Option 1: 50-100 mg IV every 6 hours 1
  • Option 2: Continuous infusion of 200 mg/24h until stabilized 1

• Continue fluid management:

  • Maintain IV fluids with normal saline
  • Monitor electrolytes and correct imbalances

• Identify and treat precipitating cause:

  • Infections (most common trigger) 3
  • Trauma
  • Surgery
  • Medication non-compliance

3. Weight-Based Dosing for Children

Weight	Induction Dose	Maintenance Dose
Up to 10 kg	2 mg/kg IV	25 mg/24h
11-20 kg	2 mg/kg IV	50 mg/24h
Over 20 kg (prepubertal)	2 mg/kg IV	100 mg/24h
Over 20 kg (pubertal)	2 mg/kg IV	150 mg/24h

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Prevention of Future Adrenal Crises

1. Patient education:

   • Stress dosing during illness (double or triple maintenance dose) 1
   • When to seek medical attention
   • Use of emergency injectable steroids

2. Medical alert identification:

   • All patients should wear a medical alert bracelet/card 1

3. Emergency kit provision:

   • Parenteral hydrocortisone for self-administration
   • Clear instructions for use

Important Considerations and Pitfalls

• Do not delay treatment while waiting for diagnostic confirmation - adrenal crisis has high mortality if not treated promptly 3

• Gastrointestinal illness is the most common precipitant for adrenal crisis 4

• Incidence rates of adrenal crisis vary by type of adrenal insufficiency:

  • Primary adrenal insufficiency: 5.2 per 100 patient-years
  • Secondary adrenal insufficiency: 3.6 per 100 patient-years
  • Tertiary (glucocorticoid-induced): 15.1 per 100 patient-years 5

• Comorbidities significantly increase the risk of adrenal crisis 5

• Drug interactions: Medications that induce CYP3A4 may increase hydrocortisone metabolism, requiring higher doses 1

• Recent etomidate administration can suppress cortisol production and should be considered when evaluating adrenal function 1