Acute adrenal crisis

Dr Hemanth
House surgeon
MMC&RI
Mysore
 Case scenario
• A 38 year old female admitted to the emergency
department complaining of progressive fatigue for 2
weeks, she went to her primary physician 4 days back
and was told that everything was fine on her blood
workup and that her fatigue was due to depression
• She also complains of fever, nausea and vomiting and
she lost about 7kg weight in the past 2 weeks
• She becomes short of breath when walking only 5 –
10 feet
• Past medical history
– K/c/o hypertension since past 5 years and on
regular medication
• Social history
– Single parent; has 2 teenage children living with
her
– Lost job 1 month back
• Physical examination
– Vital signs : Blood pressure 86/40, Pulse 118,
Respiration 18 cpm, Temperature 101 F
– Appears pale, dehydrated and malnourished
– Rest of examination unremarkable
• Lab results shows
Hemoglobin 11 mg/dl
Leukocyte count 16000 /mm3
Na+ 122 mEq/l
K+ 5.8 mEq/l
Cl- 98 mEq/l
Glucose 52 mg/dl
Cortisol 2.5 mcg/dl
ACTH 530 pg/ml
Chest x ray

Shows cavitating
lesion in left
upper lobe and
patchy opacities
throught the
both the lung
fields noted
Abdominal CT

Shows bilaterally
enlarged adrenal
glands
• Probable dignosis ?
 Acute adrenal crisis
• Life threatening emergency
• Triggered by increase in stress level
• The body is unable to release sufficient
cortisol to respond appropriately
• May lead to shock and vascular collapse
 Precipitating factors
• Severe stress
• E,g - Infections, trauma, surgery, prolonged fasting
psychological stress
• Sudden discontinuation of glucocorticoids
after prolonged therapy
• Bilateral adrenal hemorrhage/infarction
• Sudden destruction of pitutary gland
 Clinical presentation
• Dehydration, Hypotension, Shock out of proportion
to underlying illness
• Fever
• Nausea, Vomiting, diarrhea
• Severe abdominal pain
• Dizziness, headache, fatigue
• Confusion, Impaired consciousness, coma
• Electrolyte distuturbance
• Hyperpigmentation in non-sun exposed areas
 Diagnosis
• Based on clinical suspicion
• In patients with known adrenal insufficiency
• Exogenous glucocorticoid treatment
• Shock refractory to fluids and vasopressors

• Adrenal crisis is conisedered in patients with

severe hypotension refractory to fluid
resuscitation and/or vasopressors
 Laboratory findings
• Serum cortisol level
• The diagnosis of adrenal insufficiency depends upon the
demonstration of inappropriately low cortisol secretion
• Serum cortisol concentrations are normally highest in
the early morning hours (6:00 - 8:00 AM), ranging
between 10 – 20 mcg/dL 
• Serum cortisol level < 3 mcg/dl determined at 8 AM
strongly suggestive of adrenal insufficiency
• Serum cortisol level <18 mcg/dl after ACTH stimulation
test suggests adrenal insufficiency
 Normal Definitive
diagnosis

8 AM >18 mcg/dl < 3 mcg/dl

ACTH > 18 < 18

stimulation mcg/dl mcg/dl
• ACTH stimulation test
• Synthetic ACTH 250 mcg is given intreamuscularly
• Cortisol level is measured at 30 min and 60 min
after ACTH injection
• Serum cortisol level less than 20 mcg/dl indicates
adrenal insufficiency
• Low-Dose ACTH stimulation test
• In Secondary adrenal insufficiency of recent onset,
the adrenal glands will have not yet atrophied,
and will still be capable of responding to ACTH
stimulation normally
• In these cases, a low-dose ACTH stimulation test is
required to confirm the diagnosis
• Electrolyte abnormality
• Hyponatremia
• Hyperkalemia
• Hypercalcemia
• Hypoglycemia
• Normal anion gap metabolic acidosis
• CBC
• Mild anemia, lymphocytosis, eosinophilia
• Cultures
• Blood culture, sputum culture, urine culture may
be positive if bacterial infection is the precipitating
cause
 Imaging studies
• CXR – to screen for tuberculosis
• Abdominal CT
• To evaluate adrenal glands
• In tuberculous adrenalitis, the CT scan shows
initially hyperplasia of the adrenal glands and
subsequently spotty calcifications during the late
stages of the disease
• Head CT or MRI
• If secondary adrenal insufficiency is suspected
 Treatment
• Establish IV access with two large-bore
peripheral IV lines
• Blood is drawn for routine investigations and
blood culture
• Administer hydrocortisone
• Hydrocortisone 100 mg IV stat
• Then 200 mg IV over 24 hours, as 50 mg IV every 6
hours
• Fluid resuscitation with 2-3 L of normal saline
in the first hour 
• Treat hypoglycemia with IV dextros
• Empirical broad spectrum antibiotics
 Prognosis
• Rapid treatment is usually lifesaving in acute
adrenal crisis
• If adrenal crisis is unrecognized and untreated,
shock that is unresponsive to fluid
replacement and vasopressors can result in
death
 Stress and Diabetes mellitus
• Stress and diabetes are interlinked to each
other
• As stress can both contribute to and be a
consequence of diabetes
• During stressful situations, adrenaline,
glucagon, growth hormone and cortisol play a
role in maintaining blood sugar levels
• When stressed, the body prepares itself by
ensuring that enough sugar or energy is readily
available
• Insulin levels fall, glucagon and adrenaline
levels rise and more glucose is released from
the liver
• At the same time, growth hormone and cortisol
levels rise, which causes body tissues to be less
sensitive to insulin
• As a result, more glucose is available in the
blood stream
• In patients with type 2  diabetes, stress may
make blood sugar go up and become more
difficult to control
• Patient may need to take higher doses of
diabetes medications or insulin to control
blood sugar
• Reference
– Harrison’s endocrinology 20th edition
– CMDT 2021 edition