What would be the clinical course and outcome if a female patient with undiagnosed adrenal insufficiency is discharged without glucocorticoid replacement or monitoring and then develops perforated diverticulitis causing intra‑abdominal sepsis?

Catastrophic Clinical Outcome: Untreated Adrenal Insufficiency with Perforated Diverticulitis and Sepsis

This patient would almost certainly die from adrenal crisis precipitated by septic shock, as the combination of undiagnosed adrenal insufficiency and severe intra-abdominal sepsis creates a lethal physiologic cascade that cannot be survived without immediate glucocorticoid replacement. 1, 2, 3

The Fatal Pathophysiologic Sequence

Immediate Deterioration (Hours 0-24)

The patient with unrecognized adrenal insufficiency discharged without treatment would experience rapid clinical collapse once perforated diverticulitis develops:

• Septic shock from bowel perforation triggers massive glucocorticoid demand that cannot be met by non-functioning adrenal glands, leading to refractory hypotension unresponsive to fluid resuscitation and vasopressors 1, 4, 5
• Severe hyponatremia (typically <120 mEq/L) develops from combined mineralocorticoid deficiency and inappropriate ADH secretion, causing altered mental status and seizures 1, 2, 3
• Life-threatening hyperkalemia occurs from aldosterone deficiency, precipitating cardiac arrhythmias and potential cardiac arrest 1, 5
• Profound hypoglycemia results from impaired gluconeogenesis without cortisol, causing confusion, seizures, and coma 3, 5

The Adrenal Crisis Cascade (24-48 Hours)

Without glucocorticoid replacement, the patient enters full adrenal crisis:

• Cardiovascular collapse manifests as refractory hypotension (systolic BP <80 mmHg) despite aggressive fluid resuscitation, because cortisol is essential for vascular responsiveness to catecholamines 1, 6, 5
• Severe nausea and intractable vomiting prevent any oral intake, accelerating dehydration and electrolyte derangements 1, 3
• Altered mental status progressing to coma develops from combined hypoglycemia, hyponatremia, and cerebral hypoperfusion 3, 5
• Multi-organ failure ensues as hypotension and hypoperfusion damage kidneys, liver, and brain 4, 5

Terminal Phase (48-72 Hours)

The autopsy findings of sepsis, diverticulitis, and bowel perforation tell the complete story:

• Bilateral adrenal hemorrhage may occur as a terminal event in 15% of patients who die in shock, representing the final insult to already non-functioning adrenals 2
• Generalized peritonitis from perforated diverticulitis progresses unchecked without surgical intervention, with fecal contamination causing overwhelming polymicrobial sepsis 1, 4
• Septic shock becomes irreversible without the permissive effects of cortisol on vascular tone and immune function 4, 6, 5
• Death occurs from cardiovascular collapse with terminal arrhythmias from hyperkalemia, or from multi-organ failure 1, 2, 5

Why This Outcome Was Inevitable

The Dual Pathology Creates Unsurvivable Stress

• Perforated diverticulitis with sepsis represents one of the highest physiologic stress states, requiring 200-300 mg/day of cortisol production—10-20 times normal baseline 1, 4
• Complete absence of glucocorticoid replacement in a patient with adrenal insufficiency means zero cortisol availability when demand is maximal 1, 3
• The mortality rate approaches 100% for untreated adrenal crisis in the setting of severe sepsis, as documented in autopsy studies showing 15% of shock deaths have bilateral adrenal hemorrhage 2, 5

Critical Missed Interventions

The patient was denied multiple life-saving interventions:

• No stress-dose hydrocortisone (100 mg IV bolus followed by 100-300 mg/day continuous infusion) that is mandatory for adrenal crisis 1
• No emergency surgical source control (Hartmann's procedure or primary resection) for perforated diverticulitis with peritonitis 1, 4
• No broad-spectrum IV antibiotics (piperacillin-tazobactam or ceftriaxone plus metronidazole) for intra-abdominal sepsis 1, 7, 4
• No aggressive fluid resuscitation (3-4 liters isotonic saline initially) to combat hypovolemic shock 1
• No patient education about emergency glucocorticoid administration or recognition of adrenal crisis symptoms 1

The Autopsy Findings Confirm the Diagnosis

The post-mortem examination revealing sepsis, diverticulitis, and bowel perforation demonstrates:

• Sigmoid colon perforation with fecal peritonitis, consistent with Hinchey IV perforated diverticulitis requiring emergent surgery 1
• Polymicrobial sepsis from mixed aerobic and anaerobic colonic flora (E. coli, Bacteroides fragilis, Enterococcus) 1, 7
• Evidence of adrenal insufficiency likely including small, atrophic adrenals (if autoimmune) or hemorrhagic adrenals (if acute crisis-related), hyponatremia on post-mortem chemistry, and absence of stress response 2, 3

Preventable Death Through Standard Care

This death was entirely preventable with appropriate management:

• Diagnosis of adrenal insufficiency requires only morning cortisol <5 µg/dL with elevated ACTH, or cosyntropin stimulation test showing peak cortisol <18 µg/dL 1, 3
• Glucocorticoid replacement with hydrocortisone 15-25 mg/day in divided doses prevents baseline adrenal insufficiency 1, 3
• Emergency glucocorticoid kit (hydrocortisone 100 mg IM injection) allows patient self-administration during acute illness before reaching hospital 1, 3
• Patient education about doubling or tripling oral doses during illness, and immediate ER presentation for vomiting or severe illness, prevents progression to crisis 1
• Medical alert identification ensures emergency providers recognize adrenal insufficiency and administer stress-dose steroids immediately 1

The Compounding Effect of Septic Shock

The perforated diverticulitis created the perfect storm:

• Septic shock increases cortisol requirements to 200-300 mg/day hydrocortisone equivalent, far exceeding any endogenous production capacity 1, 4, 6
• Vomiting from peritonitis prevents oral glucocorticoid absorption even if the patient had medication at home 1, 4
• NPO status required for surgery means no oral intake possible, necessitating IV glucocorticoid administration 4
• Relative adrenal insufficiency can develop even in patients with normal adrenal function during severe sepsis, making absolute adrenal insufficiency uniformly fatal without treatment 6

This case represents a catastrophic failure of diagnosis and discharge planning, resulting in preventable death from the synergistic effects of untreated adrenal insufficiency and surgical sepsis. 1, 2, 3, 5