What are the symptoms of adrenal crisis in a patient with adrenal insufficiency, particularly in relation to decreased appetite and fatigue?

Symptoms of Adrenal Crisis

Yes, decreased appetite and fatigue are cardinal symptoms of adrenal crisis and adrenal insufficiency—fatigue occurs in 50-95% of patients and decreased appetite (anorexia) with weight loss occurs in 43-73% of cases. 1

Core Clinical Presentation

Adrenal crisis presents with a constellation of symptoms that progress rapidly and can be fatal if not immediately recognized:

Gastrointestinal Symptoms

• Nausea and vomiting occur in 20-62% of patients and are frequently severe 2, 1
• Decreased appetite (anorexia) and weight loss occur in 43-73% of patients with adrenal insufficiency 1
• Abdominal pain is common and may mimic an acute abdomen 2
• Severe vomiting and/or diarrhea are common precipitating events and presenting symptoms 2

Constitutional Symptoms

• Fatigue is the most common symptom, occurring in 50-95% of patients 1
• Profound weakness and malaise develop rapidly, often within hours 2, 3
• Muscle pain and cramps are frequently reported 2
• Joint pain may accompany the muscle symptoms 3

Cardiovascular Manifestations

• Hypotension (often severe) and shock are hallmark features 2
• Postural (orthostatic) hypotension occurs early, before supine hypotension develops 2
• Dehydration and volume depletion are key pathophysiologic features 2

Neurological Symptoms

• Drowsiness and somnolence are early warning signs 2, 3
• Altered mental status progresses from non-specific malaise to confusion 2
• Loss of consciousness and coma can occur in severe cases if treatment is delayed 2

Laboratory Findings That Accompany These Symptoms

• Hyponatremia is present in approximately 90% of newly presenting cases 2
• Hyperkalemia occurs in only ~50% of cases, so its absence does not exclude the diagnosis 2
• Increased creatinine due to prerenal renal failure from volume depletion 2
• Hypoglycemia may occur, particularly in children 2
• Mild hypercalcemia occurs in 10-20% of patients 2

Critical Clinical Pitfall

The absence of hyperkalemia cannot rule out adrenal insufficiency or crisis—it is present in only about 50% of cases. 2 Do not wait for "classic" electrolyte abnormalities before treating suspected adrenal crisis, as this delay can be fatal 2, 3

When to Suspect Adrenal Crisis

Consider adrenal crisis in any patient presenting with:

• Unexplained collapse or hypotension 2
• Vomiting or diarrhea with electrolyte abnormalities 2
• The combination of fatigue, decreased appetite, weight loss, nausea, and hypotension 1
• Symptoms developing rapidly (within hours) out of seemingly robust health 3

Emergency Management Priority

Treatment should never be delayed by diagnostic procedures when adrenal crisis is suspected—immediately administer hydrocortisone 100 mg IV bolus and start 0.9% saline infusion at 1 L over the first hour 2. Blood for diagnostic testing (cortisol, ACTH, electrolytes) should be drawn before treatment begins, but treatment must not be delayed waiting for results 2