What is the best course of action for a patient with suspected adrenal insufficiency, presenting with hypotension, exhaustion, and diarrhea, and lab results showing low serum cortisol and elevated adrenocorticotropic hormone (ACTH)?

Emergency Management of Adrenal Crisis

This patient is experiencing an adrenal crisis and requires immediate treatment with intravenous hydrocortisone 100 mg bolus followed by fluid resuscitation with normal saline. 1

Diagnosis

The patient's presentation strongly suggests adrenal crisis:

• Clinical features: hypotension, exhaustion, diarrhea 2
• Laboratory findings: serum cortisol of 25 with ACTH of 16 2

While the cortisol level may appear normal, in the setting of acute stress and hypotension, this represents a relative adrenal insufficiency requiring immediate intervention. 3

Immediate Management

1. Administer hydrocortisone 100 mg IV bolus immediately without waiting for additional diagnostic confirmation 2, 1

2. Begin rapid IV fluid resuscitation with 0.9% normal saline:

   • Initial rate: 1 L over the first hour
   • Continue with 3-4 L over the next 24-48 hours with frequent hemodynamic monitoring 2, 1

3. Continue glucocorticoid administration:

   • Hydrocortisone 100-300 mg/day as continuous infusion or divided IV/IM doses every 6 hours 1, 4
   • Continue until hemodynamically stable 4

4. Obtain additional laboratory studies (if not delaying treatment):

   • Basic metabolic panel (Na, K, CO2, glucose)
   • Blood cultures and other tests to identify precipitating infection 2

5. Consider ICU admission for close monitoring, especially if severely hypotensive or showing altered mental status 2, 1

Subsequent Management

1. Taper parenteral glucocorticoids over 1-3 days once the patient stabilizes 2, 1

2. Transition to oral maintenance therapy:

   • Hydrocortisone 15-25 mg daily in divided doses (typically 2/3 in morning, 1/3 in early afternoon) 2
   • Fludrocortisone 0.05-0.1 mg daily for mineralocorticoid replacement if primary adrenal insufficiency is confirmed 2, 5

3. Investigate underlying cause:

   • Evaluate for precipitating factors (infection, medication changes, stress) 2, 1
   • Determine if primary (adrenal) or secondary (pituitary) insufficiency based on ACTH and cortisol relationship 2

Prevention of Future Crises

1. Patient education:

   • Stress dosing guidelines during illness or stress 2, 1
   • Self-injection of parenteral hydrocortisone 2
   • Recognition of early symptoms of adrenal insufficiency 2

2. Medical identification:

   • Medical alert bracelet/necklace
   • Steroid emergency card 2, 1

3. Regular follow-up:

   • Annual assessment of health, weight, blood pressure, and electrolytes 2
   • Monitoring for development of other autoimmune disorders if autoimmune adrenalitis is the cause 2

Common Pitfalls to Avoid

1. Delaying treatment while waiting for confirmatory testing - treatment should never be delayed in suspected adrenal crisis 2, 1

2. Inadequate fluid resuscitation - hypotension in adrenal crisis requires aggressive fluid replacement 2, 1

3. Failure to identify and treat precipitating causes - infections and other stressors must be addressed 2, 1

4. Inadequate transition planning - clear instructions for maintenance therapy and stress dosing are essential 2

5. Overlooking mineralocorticoid replacement - patients with primary adrenal insufficiency require fludrocortisone 2, 5