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