What are the hallmark symptoms of adrenal crisis?

Hallmark Symptoms of Adrenal Crisis

Adrenal crisis presents with a constellation of cardiovascular collapse (hypotension/shock), severe gastrointestinal symptoms (nausea, vomiting, abdominal pain), profound malaise and fatigue, dehydration, and characteristic laboratory abnormalities including hyponatremia (90% of cases), hyperkalemia (50% of cases), and hypoglycemia. 1, 2, 3

Cardinal Clinical Features

Cardiovascular Manifestations

• Hypotension is the most critical hallmark, often progressing to frank shock requiring immediate intervention 1, 2, 3
• Orthostatic (postural) hypotension develops early, before supine hypotension appears, representing a critical early warning sign 2
• Severe volume depletion and dehydration are key pathophysiologic features driving the cardiovascular collapse 1, 2, 3

Gastrointestinal Symptoms

• Nausea and vomiting are often severe and represent one of the most common presenting complaints 1, 2, 3, 4
• Abdominal pain is prominent and can mimic an acute surgical abdomen 1, 2, 3
• These GI symptoms are particularly dangerous because they prevent oral medication absorption precisely when patients need increased glucocorticoid dosing most 2

Constitutional Symptoms

• Profound malaise and fatigue that develops rapidly, often within hours 1, 2, 3, 5
• Muscle pain and cramps are common musculoskeletal manifestations 1, 2, 3
• Fever may be present, either from the precipitating infection or as part of the crisis itself 4, 5

Neurological Manifestations

• Impaired cognitive function and confusion are frequent 1, 2, 3
• Altered sensorium progressing to loss of consciousness in severe cases 1, 2, 6
• Coma can occur if treatment is delayed 1, 2

Physical Examination Findings

• Hyperpigmentation of skin is a classic sign specific to primary adrenal insufficiency due to elevated ACTH levels, though this is a chronic finding rather than acute 2, 3
• Clinical dehydration with poor skin turgor and dry mucous membranes 2, 6

Laboratory Hallmarks

Electrolyte Abnormalities

• Hyponatremia is present in approximately 90% of newly presenting cases, making it the most common laboratory finding 2
• Hyperkalemia occurs in approximately 50% of patients, though its absence does not exclude the diagnosis 2
• The combination of hyponatremia with hyperkalemia is highly suggestive of adrenal crisis 2

Metabolic Derangements

• Hypoglycemia is common, particularly in children, though less frequent in adults 2
• Metabolic acidosis develops due to impaired renal function and aldosterone deficiency 2
• Mild to moderate hypercalcemia occurs in 10-20% of patients and can be severe enough to cause confusion 2, 6

Renal Function

• Increased creatinine and BUN due to prerenal renal failure from volume depletion 2
• This prerenal azotemia typically resolves with adequate fluid resuscitation 2

Hormonal Findings

• Serum cortisol below the normal range, with levels <250 nmol/L being diagnostic when combined with elevated ACTH 2
• Markedly elevated plasma ACTH level is diagnostic of primary adrenal insufficiency 2

Critical Clinical Pitfalls

• Consider adrenal crisis in any patient with unexplained collapse, hypotension, vomiting, or diarrhea, especially with electrolyte abnormalities 2
• The absence of hyperkalemia does not exclude adrenal crisis, as it is present in only half of cases 2
• Even mild gastrointestinal upset can precipitate crisis because patients cannot absorb oral medications when they need them most 2
• Treatment must never be delayed for diagnostic confirmation—if clinical suspicion exists, immediate hydrocortisone 100 mg IV and fluid resuscitation should begin before laboratory results return 1, 2, 4
• Both hypercalcemia and adrenal insufficiency may present with similar non-specific symptoms, so consider adrenal insufficiency in hypercalcemia of unclear etiology 6

Common Precipitating Factors to Elicit in History

• Gastrointestinal illness with vomiting/diarrhea is the most common trigger 1, 2, 3
• Any type of infection can precipitate crisis 1, 2, 3, 4
• Surgical procedures without adequate steroid coverage 1, 2, 3
• Physical injuries or trauma 1, 2, 3
• Medications that accelerate cortisol clearance (e.g., fluconazole) without dose adjustment 2, 6
• Failure to increase glucocorticoid doses during intercurrent illness 2