Contributor: Ricky Dhaliwal MD
Educational Pearls:
Primary adrenal insufficiency (most common risk factor for adrenal crises)
An autoimmune condition commonly known as Addison's Disease
Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids
Mineralocorticoid deficiency leads to hyponatremia and hypovolemia
Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules
Water follows sodium and generates a hypovolemic state
Glucocorticoid deficiency contributes further to hypotension and hyponatremia
Decreased vascular responsiveness to angiotensin II
Increased secretion of vasopressin (ADH) from the posterior pituitary
An adrenal crisis is defined as a sudden worsening of adrenal insufficiency
Presents with non-specific symptoms including nausea, vomiting, fatigue, confusion, and fevers
Fevers may be the result of underlying infection
Work-up in the ED includes labs looking for infection and adding cortisol + ACTH levels
Emergent treatment is required
100 mg hydrocortisone bolus followed by 50 mg every 6 hours
Immediate IV fluid repletion with 1L normal saline
The most common cause of an adrenal crisis is an acute infection in patients with baseline adrenal insufficiency
Often due to a gastrointestinal infection
References
1. Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1
2. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. doi:10.1210/jc.2015-1710
3. Cronin CC, Callaghan N, Kearney PJ, Murnaghan DJ, Shanahan F. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. 1997;157(4):456-458.
4. Feldman RD, Gros R. Vascular effects of aldosterone: sorting out the receptors and the ligands. Clin Exp Pharmacol Physiol. 2013;40(12):916-921. doi:10.1111/1440-1681.12157
5. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit