What are the signs and symptoms of an Addisonian crisis?

Addisonian Crisis: Signs and Symptoms

An Addisonian crisis presents with hypotension (often severe with shock), dehydration, gastrointestinal symptoms (nausea, vomiting, abdominal pain), profound weakness and fatigue, altered mental status ranging from confusion to coma, and characteristic laboratory abnormalities including hyponatremia (90% of cases), hyperkalemia (50% of cases), hypoglycemia, and elevated creatinine. 1, 2

Cardiovascular Manifestations

Hypotension is the hallmark cardiovascular finding and can progress rapidly to shock:

• Orthostatic (postural) hypotension develops first and represents an early warning sign before supine hypotension appears 1
• Severe hypotension requiring vasopressor support may occur 1
• Shock state with end-organ hypoperfusion in advanced cases 1, 2
• Tachycardia as a compensatory mechanism 3

The hypotension results from combined mineralocorticoid deficiency (causing sodium loss and volume depletion), glucocorticoid deficiency (impairing vasomotor tone and alpha-adrenergic receptor responsiveness), and increased vasopressin/angiotensin II impairing free water clearance 1.

Gastrointestinal Symptoms

Gastrointestinal manifestations are prominent and often the presenting complaint:

• Severe nausea and vomiting (very common) 1, 2
• Abdominal pain that can mimic an acute abdomen 1, 2
• Diarrhea (frequently part of the precipitating illness) 3, 1
• Anorexia and weight loss in chronic presentation 4

Critical pitfall: Vomiting prevents oral medication absorption precisely when patients need increased glucocorticoid doses most, creating a dangerous cycle 1.

Neurological Manifestations

Mental status changes range from subtle to severe:

• Profound weakness, malaise, and fatigue 1, 2, 5
• Impaired cognitive function and confusion 1, 2
• Lethargy and drowsiness developing within hours 6, 7
• Loss of consciousness progressing to coma in severe cases 1, 2

Dermatologic Findings

Hyperpigmentation is pathognomonic for primary adrenal insufficiency:

• Increased pigmentation of skin and mucous membranes due to elevated ACTH levels 1, 2, 4
• Particularly prominent in sun-exposed areas, skin creases, and buccal mucosa 4
• Important caveat: Hyperpigmentation develops over time in chronic adrenal insufficiency and may not be present in acute presentations or secondary adrenal insufficiency 3

Musculoskeletal Symptoms

• Muscle pain and cramps 1, 2, 5
• Joint pain 6
• Generalized weakness 6

Laboratory Abnormalities

Electrolyte disturbances are characteristic but not universally present:

• Hyponatremia occurs in approximately 90% of cases 3, 1
• Hyperkalemia is present in only 50% of patients 3, 1
• Critical teaching point: The absence of hyperkalemia does NOT exclude Addisonian crisis 1
• Hypoglycemia (more common in children than adults) 3, 1
• Mild to moderate hypercalcemia in 10-20% of patients 3, 1
• Elevated creatinine and BUN from prerenal azotemia due to volume depletion 1
• Metabolic acidosis from impaired renal function and aldosterone deficiency 3, 1

Important caveat: In the presence of severe vomiting, patients may paradoxically have hypokalaemia and alkalosis rather than the classic hyperkalemia and acidosis 3.

Hormonal Findings

• Serum cortisol below normal range (typically <250 nmol/L in acute illness is diagnostic) 3, 1
• Markedly elevated plasma ACTH level (diagnostic of primary adrenal insufficiency) 3, 1
• Low aldosterone with elevated plasma renin activity 3

Additional Laboratory Findings

• Anemia 3
• Mild eosinophilia 3
• Lymphocytosis 3
• Increased liver transaminases 3

Common Precipitating Factors

Recognizing triggers helps identify at-risk patients:

• Gastrointestinal illness with vomiting/diarrhea is the most common trigger 1, 5
• Any infection (respiratory, urinary, systemic) 1, 5, 6
• Surgical procedures without adequate steroid coverage 1, 5, 8
• Physical trauma or injury 1, 5
• Myocardial infarction 1, 5
• Severe allergic reactions 1
• Abrupt discontinuation of chronic glucocorticoid therapy 8
• Acute psychological or physical stress 6

Clinical Presentation Timeline

The evolution of symptoms differs between chronic and acute presentations:

• Chronic adrenal insufficiency typically evolves over days to weeks with insidious onset 3, 4
• Acute Addisonian crisis can develop within hours from robust health 6
• Symptoms may be nonspecific initially, mimicking sepsis or other acute processes 7

Critical Clinical Pearls

Treatment must never be delayed for diagnostic confirmation when Addisonian crisis is suspected clinically 3, 1, 5. The diagnosis should be considered in all patients presenting with unexplained collapse, hypotension, vomiting, or diarrhea, especially with electrolyte abnormalities 3, 1. Blood should be drawn for cortisol, ACTH, and electrolytes before treatment, but therapy must not be delayed waiting for results 1, 5.