How should a chronic sinus infection be managed in a patient with primary adrenal insufficiency (Addison’s disease) requiring stress‑dose glucocorticoid replacement?

Managing Chronic Sinus Infection in a Patient with Addison's Disease

Patients with Addison's disease who develop chronic sinus infections require immediate doubling or tripling of their maintenance hydrocortisone dose (to approximately 50–75 mg/day in divided doses) for the duration of active infection, with vigilant monitoring for adrenal crisis throughout treatment. 1, 2

Immediate Glucocorticoid Stress-Dosing

• Double or triple the patient's usual maintenance hydrocortisone dose immediately upon diagnosis of the sinus infection – this typically means increasing from 15–25 mg/day to 50–75 mg/day divided into 2–3 doses. 1, 3

• Maintain the increased dose for the entire duration of active infection – infections are the most common precipitant of adrenal crisis, occurring at a rate of 6–8 crises per 100 patient-years. 1, 2, 4

• Continue stress-dosing until all infectious symptoms resolve, then taper back to baseline over 1–2 days – premature dose reduction risks precipitating adrenal crisis. 1, 2

• If the patient cannot tolerate oral medications due to nausea or vomiting, administer hydrocortisone 100 mg IV or IM immediately and begin 0.9% saline infusion at 1 L over the first hour – gastrointestinal symptoms preventing oral intake constitute a medical emergency. 2, 3

Mineralocorticoid Management

• Continue the patient's usual fludrocortisone dose (typically 50–200 µg daily) without adjustment during stress-dosing when total hydrocortisone remains below 100 mg/day. 1, 3

• No additional mineralocorticoid supplementation is needed if hydrocortisone exceeds 50 mg/day – higher glucocorticoid doses provide adequate mineralocorticoid activity by saturating 11β-hydroxysteroid dehydrogenase type 2 receptors. 2, 5

Treatment of the Sinus Infection

• Initiate appropriate antimicrobial therapy promptly based on clinical presentation – bacterial sinusitis typically requires antibiotics, while fungal or viral etiologies need targeted treatment. 2

• Avoid intranasal corticosteroid sprays (especially betamethasone) in patients with established adrenal insufficiency – chronic intranasal glucocorticoid use can cause secondary adrenal suppression and complicate management. 1, 6

• Consider ENT consultation for chronic or refractory sinusitis – surgical intervention may be necessary, but requires specific perioperative glucocorticoid management (hydrocortisone 100 mg IV at induction, followed by 200 mg/24 hours continuous infusion). 1

Critical Monitoring for Adrenal Crisis

• Educate the patient to recognize warning signs of impending adrenal crisis: severe nausea/vomiting, hypotension or orthostatic dizziness, altered mental status, severe abdominal pain, or worsening fatigue despite increased glucocorticoid doses. 2, 3, 7

• Monitor blood pressure in both supine and standing positions – orthostatic hypotension (a drop >20 mmHg systolic) is an early warning sign that precedes supine hypotension. 2, 3

• If any crisis features develop, the patient should self-administer their emergency hydrocortisone 100 mg IM injection immediately and proceed to the emergency department – delays in treatment increase mortality. 2, 3, 4

• Check serum sodium and potassium if the patient presents to medical care – hyponatremia occurs in 90% of adrenal crises, while hyperkalemia is present in 50% of primary adrenal insufficiency cases. 2, 3

Common Pitfalls to Avoid

• Never assume the patient is adequately educated about "sick day rules" – documented instances exist where patients receive little or no education on stress-dosing, contributing to the 8.6% of adrenal crises that occur during hospital stays due to inadequate glucocorticoid coverage. 1, 2

• Do not attribute persistent fever solely to the sinus infection – fever may be a manifestation of adrenal insufficiency itself, and glucocorticoid doses should not be reduced while the patient remains febrile. 2

• Never delay emergency hydrocortisone administration while awaiting diagnostic confirmation – if adrenal crisis is suspected clinically, give hydrocortisone 100 mg IV immediately, as there are no long-term adverse consequences of short-term high-dose glucocorticoid therapy. 1, 2

• Ensure the patient carries a medical alert bracelet and steroid emergency card – these facilitate rapid recognition and treatment by healthcare providers during acute presentations. 1, 3

Long-Term Prevention

• Verify the patient possesses a pre-filled 100 mg hydrocortisone IM injection kit and has been trained in self-administration – this enables immediate treatment if oral intake becomes impossible. 2, 3, 8

• Re-educate that any intercurrent illness—including seemingly minor infections—mandates immediate dose escalation – failure to increase glucocorticoid doses during stress is the leading cause of preventable adrenal crises. 1, 2, 4

• Schedule endocrinology follow-up after infection resolution to review stress-dosing technique, assess adequacy of baseline replacement, and screen for other autoimmune conditions (up to 50% of Addison's patients develop additional autoimmune disorders). 3, 7, 8