What are the signs and symptoms of adrenal crisis in a patient with a history of adrenal insufficiency or those taking corticosteroid medications?

Adrenal Crisis: Signs and Symptoms

Cardiovascular Manifestations

Hypotension (often severe) and shock are the hallmark cardiovascular features of adrenal crisis, frequently accompanied by profound dehydration and circulatory collapse. 1, 2

• Orthostatic (postural) hypotension develops early, occurring before supine hypotension—this represents a critical early warning sign that should not be ignored 2
• Progressive loss of vasomotor tone occurs due to impaired alpha-adrenergic receptor responses, leading to vasopressor-resistant hypotension 2
• Severe volume depletion and circulatory collapse characterize advanced cases 2
• Blood pressure should be measured in both supine and standing positions for early detection—do not wait for supine hypotension to develop 2

Gastrointestinal Symptoms

• Nausea and vomiting (often severe) are extremely common presenting symptoms 1, 2
• Abdominal pain with peritoneal irritation frequently mimics an acute surgical abdomen 1, 2
• Severe vomiting and/or diarrhea commonly precipitate the crisis and persist as presenting symptoms 2
• Even mild gastrointestinal upset can precipitate crisis as patients cannot absorb oral medications when they need them most 2

Neurological Manifestations

• Altered mental status progresses from non-specific malaise and fatigue to confusion, obtunded consciousness, and potentially coma if treatment is delayed 1, 2
• Impaired cognitive function and loss of consciousness occur in severe cases 1, 2
• Severe weakness is nearly universal 2
• Drowsiness and somnolence represent early warning signs 2

Musculoskeletal Symptoms

• Muscle pain, cramps, and joint pain are frequently reported 1, 2
• Profound weakness affecting daily function is characteristic 2

Laboratory Findings

• Hyponatremia is present in approximately 90% of newly presenting cases—this is the most common electrolyte abnormality 1, 2
• Hyperkalemia occurs in only ~50% of cases, so its absence does NOT exclude the diagnosis 1, 2
• Increased creatinine and BUN due to prerenal renal failure from volume depletion 1, 2
• Hypoglycemia is common in children but less frequent in adults 1
• Mild to moderate hypercalcemia occurs in 10-20% of patients 1
• Metabolic acidosis due to impaired renal function and aldosterone deficiency 1
• Serum cortisol below normal range with markedly elevated plasma ACTH in primary adrenal insufficiency 1

Additional Clinical Features

• Hyperpigmentation of skin is a classic sign of primary adrenal insufficiency due to elevated ACTH levels (not present in secondary adrenal insufficiency) 2
• Persistent pyrexia may be due to adrenal insufficiency itself, not just infection 2
• Salt craving suggests primary adrenal insufficiency with mineralocorticoid deficiency 2

Critical Clinical Pitfall

Consider adrenal crisis in ANY patient with unexplained collapse, hypotension, vomiting, or diarrhea, especially with electrolyte abnormalities—treatment must NEVER be delayed for diagnostic procedures when adrenal crisis is suspected. 1, 2 Immediate administration of hydrocortisone 100 mg IV bolus and 0.9% saline infusion at 1 L over the first hour is mandatory, even before laboratory confirmation 1, 2

Common Precipitating Factors to Recognize

• Gastrointestinal illness with vomiting/diarrhea is the most common trigger 1, 2
• Infections of any type 1, 2
• Surgical procedures without adequate steroid coverage 1, 2
• Physical injuries or trauma 1, 2
• Failure to increase glucocorticoid doses during intercurrent illness 2
• Medications that accelerate cortisol clearance without dose adjustment 2
• Starting thyroid hormone replacement before adequate glucocorticoid replacement in patients with multiple hormone deficiencies 2