What are the signs and symptoms of an adrenal crisis?

Signs and Symptoms of Adrenal Crisis

Adrenal crisis presents with hypotension, dehydration, malaise, fatigue, nausea, vomiting, abdominal pain, muscle pain/cramps, and potentially shock, accompanied by laboratory findings typically including hyponatremia, hyperkalemia, increased creatinine, hypoglycemia, and mild hypercalcemia. 1

Clinical Presentation

Physical and Systemic Manifestations

• Profound impairment of general well-being and malaise 2, 3
• Hypotension (often severe) and shock 2, 1
• Dehydration 1
• Fever (common during adrenal crisis) 3
• Hyperpigmentation of skin (classic sign of primary adrenal insufficiency due to elevated ACTH levels) 1

Gastrointestinal Symptoms

• Nausea and vomiting (often severe) 2, 1
• Abdominal pain 2, 1
• Diarrhea may be present 4

Neurological Manifestations

• Impaired cognitive function 2, 1
• Confusion 2, 1
• Loss of consciousness 2, 1
• Coma in severe cases 2, 1

Musculoskeletal Symptoms

• Muscle pain and cramps 2, 1
• Generalized weakness 3

Laboratory Findings

Electrolyte Abnormalities

• Hyponatremia (present in approximately 90% of newly presenting cases) 5
• Hyperkalemia (found in approximately 50% of patients) 5
• Mild to moderate hypercalcemia (occurs in 10-20% of patients) 5
• Important caveat: In the presence of severe vomiting, patients may paradoxically present with hypokalemia and alkalosis rather than the expected hyperkalemia 5

Other Laboratory Abnormalities

• Increased creatinine and BUN due to prerenal renal failure from volume depletion 5
• Hypoglycemia (common in children but less frequent in adults) 5
• Metabolic acidosis due to impaired renal function and aldosterone deficiency 5
• Elevated liver transaminases in some patients 5
• Anemia, mild eosinophilia, and lymphocytosis may be present 5

Hormonal Findings

• Serum cortisol below the normal range 5
• Markedly elevated plasma ACTH level in primary adrenal insufficiency 5
• Increased plasma renin activity (PRA) 5
• Low serum aldosterone and dehydroepiandrosterone sulfate (DHEAS) levels 5

Common Precipitating Factors

• Gastrointestinal illness with vomiting/diarrhea (most common trigger) 2
• Infections (any type) 2, 3
• Surgical procedures without adequate steroid coverage 2
• Physical injuries or trauma 2
• Myocardial infarction 2
• Severe allergic reactions 2
• Severe hypoglycemia in diabetic patients 2
• Failure to adjust glucocorticoid doses during times of physiological stress 6

Clinical Pearls and Pitfalls

• Treatment should never be delayed by diagnostic procedures when adrenal crisis is suspected 5
• Even a mild upset stomach may precipitate an adrenal crisis as patients cannot absorb their oral medication when they need it most 7
• The diagnosis is often missed due to the variety of nonspecific signs and symptoms 8
• Adrenal crisis contributes significantly to the excess mortality seen in patients with adrenal insufficiency 3
• The incidence of adrenal crisis is estimated at 5-10 adrenal crises per 100 patient-years with a mortality rate of approximately 0.5 per 100 patient-years 3

Recognition in Emergency Settings

• Consider adrenal crisis in any patient with unexplained collapse, hypotension, vomiting, or diarrhea, especially with electrolyte abnormalities 5
• Serum cortisol <250 nmol/L with increased ACTH is diagnostic of primary adrenal insufficiency 5
• Serum cortisol <400 nmol/L with increased ACTH during acute illness raises strong suspicion of primary adrenal insufficiency 5
• Blood for diagnostic testing should be drawn before treatment, but treatment must not be delayed waiting for results 5

Remember that adrenal crisis is a life-threatening emergency requiring immediate intervention with hydrocortisone and fluid resuscitation. Early recognition of the signs and symptoms is crucial for preventing mortality 9.