What symptoms of adrenal insufficiency require hospitalization?

Symptoms of Adrenal Insufficiency Warranting Hospitalization

Patients with adrenal insufficiency should be hospitalized immediately when presenting with severe symptoms such as adrenal crisis, severe headache, visual field deficiency, hypotension, altered mental status, or symptoms refractory to outpatient management. 1, 2

Symptoms Requiring Immediate Hospitalization

Adrenal Crisis

• Hypotension/shock requiring vasopressors 2
• Fever, chills, sweats, or hypothermia 2
• Altered mental status or encephalopathy 3
• Severe dehydration 2
• Severe electrolyte abnormalities (particularly hyponatremia and hyperkalemia) 4
• Severe abdominal pain, nausea, and vomiting preventing oral medication intake 4, 5

Neurological Manifestations

• Severe headache (may indicate pituitary involvement) 1
• Visual field deficits (may indicate pituitary enlargement) 1
• Encephalopathy (can mimic infectious or autoimmune encephalitis) 3
• Focal neurological deficits 3

Clinical Assessment Algorithm

1. Vital Signs Assessment

   • Hypotension (especially postural)
   • Tachycardia
   • Fever or hypothermia
   • Respiratory distress

2. Mental Status Evaluation

   • Confusion or altered consciousness
   • Lethargy progressing to coma

3. Physical Examination Findings

   • Skin: Hyperpigmentation (in primary adrenal insufficiency)
   • Cardiovascular: Signs of shock or poor perfusion
   • Abdominal: Severe pain or tenderness

4. Laboratory Abnormalities

   • Hyponatremia (Na <130 mEq/L)
   • Hyperkalemia (K >5.5 mEq/L)
   • Hypoglycemia
   • Elevated BUN/creatinine (pre-renal pattern)

Management Approach for Hospitalized Patients

Immediate Interventions

• Administer hydrocortisone 100 mg IV bolus immediately 2
• Initiate fluid resuscitation with normal saline (10-20 ml/kg; maximum 1,000 ml) 2
• Continue hydrocortisone 50-100 mg IV every 6 hours or 200 mg/day as continuous infusion 2

Ongoing Management

• Monitor vital signs, electrolytes, and mental status
• Address precipitating factors (infection, medication changes, stress)
• Transition to oral maintenance therapy once stabilized

Important Considerations

Pitfalls to Avoid

• Delayed recognition: Symptoms of adrenal insufficiency are often nonspecific, leading to delayed diagnosis and treatment 4, 5
• Inadequate steroid dosing: Insufficient glucocorticoid replacement during stress can precipitate adrenal crisis 2
• Failure to identify underlying cause: Primary vs. secondary adrenal insufficiency requires different management approaches 2
• Overlooking neurological presentations: Adrenal crisis can present with encephalopathy even without classic hypotension or electrolyte abnormalities 3

Patient Education Upon Discharge

• Double or triple maintenance glucocorticoid doses during illness 2
• Carry emergency injectable steroids and know when to use them 2, 5
• Wear medical alert bracelet/card for adrenal insufficiency 2
• Recognize early warning signs requiring medical attention 5

Special Populations

Glucocorticoid-Induced Adrenal Insufficiency

• Patients who have recently tapered or discontinued supraphysiological glucocorticoids are at risk 6
• Symptoms may be less obvious but can still progress to adrenal crisis requiring hospitalization 6

Patients with Multiple Autoimmune Conditions

• Higher risk of adrenal crisis due to underlying immune dysregulation 3
• May present with atypical features that mimic other autoimmune conditions 3

Remember that adrenal crisis is a medical emergency with potential fatal outcomes if not promptly recognized and treated. When in doubt about the severity of symptoms in a patient with known or suspected adrenal insufficiency, hospitalization for observation and treatment is the safest approach.