What is the treatment for an adrenal crisis?

Adrenal Crisis: Clinical Presentation and Symptoms

An adrenal crisis presents with profound hypotension and shock, accompanied by severe gastrointestinal symptoms (nausea, vomiting, abdominal pain), dehydration, altered mental status (confusion to coma), and characteristic laboratory abnormalities including hyponatremia, hyperkalemia, and prerenal azotemia. 1

Cardinal Clinical Features

Hemodynamic Manifestations

• Hypotension and circulatory shock are the defining features requiring immediate intervention 2, 3
• Dehydration with volume depletion from inadequate mineralocorticoid effect 1
• Postural hypotension may precede frank shock 1

Gastrointestinal Symptoms

• Nausea and vomiting are among the most common presenting complaints 1, 3
• Severe abdominal pain, sometimes mimicking an acute surgical abdomen with peritoneal irritation 1
• Diarrhea often accompanies or precipitates the crisis 1

Neurological Manifestations

• Impaired cognitive function ranging from confusion to complete loss of consciousness 1
• Coma can occur in severe cases 1, 3
• These neurological symptoms are "not uncommon" and should raise suspicion for adrenal crisis 1

Constitutional Symptoms

• Profound malaise and fatigue beyond typical illness 1, 3
• Muscle pain or cramps 1
• Fever (though this may reflect the precipitating infection rather than the crisis itself) 4

Laboratory Abnormalities

Electrolyte Disturbances

• Hyponatremia from combined glucocorticoid and mineralocorticoid deficiency 1, 3
• Hyperkalemia due to aldosterone deficiency 1, 3
• These electrolyte abnormalities help distinguish adrenal crisis from other shock states 3

Renal and Metabolic Findings

• Elevated creatinine and urea from prerenal renal failure secondary to volume depletion 1, 3
• Hypoglycemia, particularly in children but can occur in adults 1, 3
• Mild hypercalcemia may be present 1, 3

Common Precipitating Factors

Understanding triggers is essential for recognizing when patients are at highest risk:

Infectious Causes

• Gastrointestinal infections with vomiting and/or diarrhea are the most frequent precipitants, accounting for 30-50% of crises 1, 3, 5
• Other infections (respiratory, urinary, systemic) are major triggers 1, 4, 6
• The lack of cortisol during infection enhances pro-inflammatory cytokine release and increases sensitivity to their toxic effects 4

Surgical and Traumatic Stress

• Surgical procedures without adequate steroid coverage 1, 3, 6
• Physical injuries or trauma 1, 3
• Major pain or strenuous physical activity 6

Other Medical Stressors

• Myocardial infarction 1
• Severe allergic reactions 1, 3
• Severe hypoglycemia in diabetic patients 1, 3
• Heat exposure 6
• Pregnancy (particularly third trimester) 6

Treatment-Related Causes

• Treatment failures in poorly educated or non-compliant patients 1
• Withdrawal of glucocorticoid therapy 6
• Chronic under-replacement with mineralocorticoids predisposes to recurrent crises 1, 7

Clinical Recognition Pearls

In Primary Adrenal Insufficiency

• Hyperpigmentation of skin and mucous membranes due to elevated ACTH levels is a classic sign that may be present before crisis 2
• However, absence of hyperpigmentation does not exclude the diagnosis, especially in acute presentations 2

Critical Pitfall

Treatment must never be delayed for diagnostic confirmation - if adrenal crisis is suspected based on clinical presentation, immediate therapy with hydrocortisone and fluids should be initiated while drawing blood for cortisol and ACTH levels 1, 3

Epidemiology and Mortality

• The frequency of adrenal crises is 6-8 per 100 patient-years in those with known adrenal insufficiency 1
• More recent studies suggest an incidence of 5-10 crises per 100 patient-years 4, 8
• Mortality rate from adrenal crisis is approximately 0.5 per 100 patient-years, contributing to the excess mortality in this population 4, 6
• These events are life-threatening emergencies that respond well to prompt treatment but can be fatal if unrecognized 4, 6