What is the treatment for pericarditis caused by adrenal crisis?

Treatment of Pericarditis Caused by Adrenal Crisis

Immediate treatment requires simultaneous administration of intravenous hydrocortisone 100 mg bolus followed by 100 mg every 6-8 hours plus isotonic saline resuscitation, while treating the pericarditis with the same high-dose hydrocortisone that addresses both the adrenal crisis and provides anti-inflammatory coverage for the pericardium. 1

Immediate Emergency Management

The treatment approach must address both life-threatening conditions simultaneously:

Adrenal Crisis Treatment (Priority)

• Administer IV hydrocortisone 100 mg immediately as a bolus, followed by 100 mg every 6-8 hours (or 200-300 mg/24h as continuous infusion) until clinical recovery 1
• Initiate rapid IV isotonic (0.9%) saline at 1 L/hour until hemodynamic improvement is achieved, then continue at slower rate for 24-48 hours 1
• Blood samples for cortisol and ACTH should be drawn before treatment, but never delay treatment for diagnostic procedures 1
• The high-dose hydrocortisone (100 mg) saturates mineralocorticoid receptors, providing both glucocorticoid and mineralocorticoid effects needed in crisis 1

Pericarditis Management in This Context

• The high-dose hydrocortisone used for adrenal crisis simultaneously treats the pericarditis, as it provides potent anti-inflammatory effects 1, 2
• Do NOT add NSAIDs or aspirin during the acute crisis phase due to hemodynamic instability and potential complications 1
• Colchicine should NOT be initiated during acute adrenal crisis but can be considered once stabilized 1, 3

Assessment for Cardiac Tamponade

Given the association between adrenal crisis and pericardial complications:

• Perform immediate echocardiography to assess for pericardial effusion and tamponade physiology 4, 5, 6
• If hemodynamic compromise from tamponade is present, emergent pericardiocentesis is indicated while continuing hydrocortisone therapy 1, 4
• Pericardial fluid analysis typically shows neutrophilic predominance with negative infectious workup in adrenal insufficiency-related pericarditis 6

Transition Phase (After Initial Stabilization)

Once hemodynamically stable (typically 24-48 hours):

Glucocorticoid Tapering

• Taper parenteral hydrocortisone over 1-3 days to oral replacement doses (15-25 mg daily in split doses) 1
• Continue physiologic replacement indefinitely: 15 mg in morning, 10 mg in afternoon, with first dose immediately upon waking 1
• Add fludrocortisone 50-200 mcg daily once transitioned to oral therapy for mineralocorticoid replacement 1

Pericarditis-Specific Treatment

• Once oral intake is tolerated and patient is stable, transition to standard pericarditis regimen: aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours with gastroprotection 1, 3
• Add colchicine 0.5 mg twice daily (≥70 kg) or 0.5 mg once daily (<70 kg) for 3 months to prevent recurrence 1, 3
• Monitor CRP levels to guide treatment duration and assess response 1, 3

Critical Pitfalls and Caveats

High Risk of Recurrence

• Pericarditis in autoimmune polyglandular syndrome (which includes adrenal insufficiency) has high recurrence rates despite adequate glucocorticoid replacement 6
• Recurrent pericarditis may occur even on physiologic replacement doses and requires high-dose anti-inflammatory therapy for each episode 6
• Patients require long-term vigilance for recurrent pericardial symptoms 6

Steroid Dosing Distinction

• Stress-dose steroids (100 mg hydrocortisone) are NOT the same as anti-inflammatory doses for pericarditis 1
• During acute crisis, the 100 mg doses serve dual purpose: treating adrenal insufficiency AND providing anti-inflammatory effect 1
• Once on maintenance therapy, do NOT use low-dose replacement steroids as primary pericarditis treatment—use NSAIDs/colchicine as first-line 1, 3

Ongoing Management Considerations

• All patients must wear medical alert identification and carry steroid emergency card 1
• Provide emergency hydrocortisone injection kit for self-administration during future illnesses 1, 7
• Patient education is critical: any infection, stress, or illness requires doubling or tripling of maintenance hydrocortisone dose 1, 7
• Exercise restriction until symptoms resolve and CRP normalizes (minimum 3 months for athletes) 1, 3

Treatment of Refractory Cases

If pericarditis persists or recurs despite adequate adrenal replacement:

• Consider immunosuppressive agents (azathioprine, methotrexate, mycophenolate mofetil) for corticosteroid-dependent recurrent pericarditis 1, 8
• Anakinra (IL-1 receptor antagonist) or IVIG may be considered for refractory cases 1, 9
• Pericardiectomy is last resort only after exhaustive medical therapy failure 1

Long-Term Follow-Up

• Annual review minimum with assessment of well-being, weight, blood pressure, and serum electrolytes 1
• Monitor for development of other autoimmune conditions, particularly hypothyroidism, as these patients often have autoimmune polyglandular syndrome 1, 5, 6
• Bone density monitoring every 3-5 years due to glucocorticoid effects 1
• Maintain high index of suspicion for recurrent pericarditis in this population 6