hypoadrenal (Addisonian) crisis; acute adrenal insufficiency

Introduction

Hypoadrenal (Addisonian) crisis occurs secondary inadequate release of glucocorticoids & mineralocorticoids from the adrenal cortex.

Etiology

• acute adrenal hemorrhage
• precipitating factors in patient's with Addison's disease
  • infection, especially gastroenteritis with vomiting, diarrhea, dehydration
  • injury
  • surgery
  • less commonly
    • exercise & emotional upset less frequently
    • minor medical procedures such as vaccinations or infusions
    • immunotherapy or chemotherapy
• abrupt discontinuation of glucocorticoid therapy
• risk factors
  • older age
  • history of prior adrenal crises
  • autoimmune polyglandular syndromes
  • type 1 diabetes mellitus
  • asthma
  • cardiac disease

Clinical manifestations

• hypotension, shock
• acute abdominal symptoms
• delirium, obtundation, or both
• hyponatremia, hyperkalemia, hypoglycemia
• pyrexia
• some patients may have multiple episodes

Laboratory

• chem 7
  • serum Na+: hyponatremia
  • serum K+: hyperkalemia
  • serum Cl- allows calculation of anion gap
  • serum bicarbonate: low due to metabolic acidosis
  • serum glucose: hypoglycemia
• serum cortisol
• eosinophil count may be elevated (eosinophilia)

Management

• volume expansion with intravenous saline
• hydrocortisone 100 mg IV every 8 hours
  • marked resolution of hypotension within 1 hour
  • improvement in clinical symptoms within 2 hours
• parenteral administration of hydrocortisone at home may prevent progression of an early adrenal crisis
  • subcutaneous administration of hydrocortisone is an alternative to intramuscular injection (off-label)

More general terms

• hypovolemic shock
• Addison's disease (primary adrenal failure)