Adrenal crisis
Adrenal crisis is life-threatening acute glucocorticoid deficiency, most often precipitated by infection or another physiologic stress in a patient with known or unrecognized adrenal insufficiency, presenting with dehydration, hypotension, or shock out of proportion to the concurrent illness. Treatment is immediate intravenous hydrocortisone 100 mg followed by 50 mg every 6 hours plus isotonic saline with dextrose, without waiting for confirmatory labs.
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What this article covers
- Overview
Adrenal crisis is acute, severe glucocorticoid deficiency, a medical emergency defined by dehydration, hypotension, or frank shock that is out of proportion to the severity of the precipitating illness.
- Epidemiology
Occurs in patients with pre-existing adrenal insufficiency, primary or secondary, or in patients on chronic glucocorticoid therapy who abruptly stop or under-dose during illness.
- Risk factors
Established primary or secondary adrenal insufficiency, especially when the patient has not been instructed in sick-day dose adjustment.
- Pathophysiology
Cortisol is required for vascular tone and catecholamine responsiveness: cortisol upregulates vascular alpha-1 adrenergic receptor expression and potentiates the pressor effect of catecholamines, so…
- Clinical features
Hypotension or frank shock disproportionate to the concurrent illness is the hallmark that should trigger suspicion, especially when the patient does not respond to usual fluid and vasopressor therapy.
- Differential diagnosis
Septic shock: distributive shock with a clear infectious source and typically preserved or elevated cortisol as part of the stress response, unlike the inappropriately low cortisol of adrenal crisis; the two can coexist.
- Diagnosis
First, this is a clinical diagnosis at the bedside: unexplained hypotension or shock disproportionate to the current illness, with or without hyponatremia, hyperkalemia, hypoglycemia, or known…
- Management
First, establish IV access and give hydrocortisone 100 mg IV bolus immediately, without waiting for confirmatory cortisol or ACTH results, since delay in a true crisis is fatal.
- Complications
Death from refractory shock, the principal danger when treatment is delayed while awaiting labs or when the diagnosis is not considered.
- Prognosis
Rapid, appropriate treatment reverses the crisis quickly, with hemodynamic improvement typically evident within hours of the first hydrocortisone dose.
- Prevention
Every patient with known adrenal insufficiency should be instructed in sick-day rules: double to triple the usual oral glucocorticoid dose for 2-3 days during fever, infection, or other minor to moderate physiologic stress.
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Related articles
- Primary adrenal insufficiency
Primary adrenal insufficiency (Addison disease) is destruction or dysfunction of the adrenal cortex, most often autoimmune, causing combined cortisol and aldosterone deficiency with hyperpigmentation, hyponatremia, and hyperkalemia. Lifelong glucocorticoid replacement with hydrocortisone plus mineralocorticoid replacement with fludrocortisone is required, with sick-day dose increases to prevent adrenal crisis.
- Secondary adrenal insufficiency
Secondary adrenal insufficiency is ACTH deficiency from pituitary or hypothalamic disease, or most commonly from withdrawal of prolonged exogenous glucocorticoid therapy, causing isolated cortisol deficiency without hyperpigmentation or hyperkalemia because aldosterone secretion is preserved. Lifelong glucocorticoid replacement with hydrocortisone, with dose increases during illness, prevents adrenal crisis.
- Pituitary apoplexy
Pituitary apoplexy is sudden hemorrhage or infarction of a pituitary adenoma causing severe headache, visual loss, ophthalmoplegia, and acute adrenocorticotropic hormone (ACTH) deficiency, and is a medical emergency. First-line treatment is immediate IV hydrocortisone given empirically before confirmatory testing when adrenal insufficiency is suspected, with urgent pituitary MRI and surgical decompression reserved for progressive visual loss.