Can adrenal crisis present with shivering in a patient with a history of chronic prednisolone (corticosteroid) use and current acute gastroenteritis?

Can Adrenal Crisis Present with Shivering?

Shivering is not a recognized or documented presenting feature of adrenal crisis in the medical literature or clinical guidelines. The classic presentation involves hypotension, dehydration, nausea, vomiting, abdominal pain, altered mental status, and electrolyte abnormalities—but shivering is notably absent from these descriptions 1.

Core Clinical Features of Adrenal Crisis

The established presenting features include 1:

• Cardiovascular: Hypotension (often severe), shock, orthostatic hypotension
• Gastrointestinal: Nausea, vomiting (often severe), abdominal pain
• Neurological: Confusion, altered mental status, weakness, malaise, potentially coma
• Metabolic: Hyponatremia (90% of cases), hyperkalemia (50% in primary AI), hypoglycemia (more common in children)

Context: Gastroenteritis as a Precipitant

Gastroenteritis is the most common trigger for adrenal crisis, particularly in patients on chronic corticosteroids like prednisolone 2, 1. In your clinical scenario, the patient's acute gastroenteritis represents a critical stress situation where:

• Oral prednisolone absorption is compromised due to vomiting/diarrhea 1
• The patient cannot take or retain their usual glucocorticoid dose when they need it most 1
• This creates a mismatch between cortisol demand and supply, precipitating crisis 3

What Shivering Might Actually Represent

If your patient is shivering, consider these alternative explanations:

Fever from underlying infection 1:

• The gastroenteritis itself may be febrile
• Adrenal crisis can present with persistent pyrexia 1
• However, shivering/rigors specifically are not part of the adrenal crisis syndrome

Sepsis or severe infection 4:

• The clinical picture may resemble sepsis 4
• Shivering could indicate bacteremia or severe systemic infection
• This would be a precipitant OF adrenal crisis, not a feature of it

Hypoglycemia 1:

• More common in children but can occur in adults with adrenal crisis
• Hypoglycemia can cause tremor and shivering-like symptoms

Critical Action Points for This Patient

Immediate management is required regardless of whether shivering is present 1, 5:

1. Administer hydrocortisone 100 mg IV bolus immediately without waiting for diagnostic confirmation 1, 5
2. Start aggressive fluid resuscitation with 0.9% saline at 1 liter over the first hour 1, 5
3. Draw blood for cortisol, ACTH, electrolytes before treatment, but do not delay therapy 1
4. Continue hydrocortisone 200 mg per 24 hours as continuous IV infusion or 50 mg IV every 6 hours 1, 5

Common Pitfall to Avoid

Do not dismiss the possibility of adrenal crisis simply because the presentation includes atypical features like shivering 1. The European Society of Endocrinology emphasizes that treatment must never be delayed for diagnostic procedures when clinical suspicion exists 1. In a patient with chronic prednisolone use presenting with gastroenteritis, hypotension, weakness, or altered mental status, assume adrenal crisis and treat immediately 1, 5.

The mortality rate is 0.5 per 100 patient-years when treatment is delayed 6, making prompt recognition and intervention paramount even when the presentation is not textbook.