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Adrenal Crisis Clinical Presentation

  • Author: Lisa Kirkland, MD, FACP, FCCM, MSHA; Chief Editor: George T Griffing, MD  more...
 
Updated: Jun 29, 2016
 

History

History can include the following:

  • Prior steroid use: Use involves at least 20 mg daily of prednisone or its equivalent for at least 5 days within the past 12 months. Patients receiving doses close to normal physiologic levels require only 1 month to recover normal adrenal function.
  • Organisms associated with adrenal crisis (eg, Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumonia, fungi)
  • Meningococcemia
  • Severe physiologic stress[6] (eg, sepsis, trauma, burns, surgery): In a retrospective review of patients from a level 1 trauma center, Guillamondegui et al found that trauma patients with acute adrenal insufficiency who were treated for the condition had shorter hospital stays and required fewer days in the intensive care unit and on a ventilator than did untreated patients.[7] In addition, the authors concluded that recognition and treatment of the condition can reduce trauma patient mortality by almost 50%.
  • Anticoagulants, hemorrhagic diathesis
  • Newborn, complicated pregnancy
  • Adrenocorticotropin therapy, known primary or secondary adrenocortical insufficiency
  • Invasive or infiltrative disorders
  • Topical steroids: Risk of adrenal crisis occurs when used over a large surface area for a prolonged duration, using occlusive dressings and a highly potent drug.
  • Inhaled steroids: Use of a high dose (>0.8mg/d) over a prolonged duration increases risk; fluticasone may cause suppression at lower dose.
  • Congenital adrenal hyperplasia (CAH): A retrospective study by Rushworth et al indicated that in pediatric patients with CAH, adrenal crises occur mostly in the younger ones. The study, which evaluated 573 admissions for medical problems in children with CAH, found that 21 of 37 adrenal crises occurred in patients aged 1-5 years, with another six in children aged up to 1 year.[8]
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Physical

See the list below:

  • Unexplained shock, usually refractory to fluid and pressor resuscitation
  • Nausea, vomiting, abdominal or flank pain
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Causes

See the list below:

  • Rapid withdrawal of long-term steroid therapy
  • Ketoconazole
  • Phenytoin
  • Rifampin
  • Mitotane
  • Septic shock
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Contributor Information and Disclosures
Author

Lisa Kirkland, MD, FACP, FCCM, MSHA Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; Vice Chair, Department of Critical Care, ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, FCCM, MSHA is a member of the following medical societies: American College of Physicians, Society of Hospital Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

David M Klachko, MD, MEd Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Missouri-Columbia School of Medicine

David M Klachko, MD, MEd is a member of the following medical societies: Alpha Omega Alpha, Missouri State Medical Association, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, Endocrine Society, Sigma Xi

Disclosure: Nothing to disclose.

References
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  2. White K, Arlt W. Adrenal crisis in treated Addison's disease: a predictable but under-managed event. Eur J Endocrinol. 2010 Jan. 162(1):115-20. [Medline].

  3. 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 Mar. 162(3):597-602. [Medline].

  4. Smans LC, Van der Valk ES, Hermus AR, Zelissen PM. Incidence of adrenal crisis in patients with adrenal insufficiency. Clin Endocrinol (Oxf). 2016 Jan. 84 (1):17-22. [Medline].

  5. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21. 288(7):862-71. [Medline]. [Full Text].

  6. Weant KA, Sasaki-Adams D, Dziedzic K, et al. Acute relative adrenal insufficiency after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2008 Oct. 63(4):645-9; discussion 649-50. [Medline].

  7. Guillamondegui OD, Gunter OL, Patel S, et al. Acute adrenal insufficiency may affect outcome in the trauma patient. Am Surg. 2009 Apr. 75(4):287-90. [Medline].

  8. Rushworth RL, Falhammar H, Munns CF, Maguire AM, Torpy DJ. Hospital Admission Patterns in Children with CAH: Admission Rates and Adrenal Crises Decline with Age. Int J Endocrinol. 2016. 2016:5748264. [Medline]. [Full Text].

  9. Arlt W. The approach to the adult with newly diagnosed adrenal insufficiency. J Clin Endocrinol Metab. 2009 Apr. 94(4):1059-67. [Medline].

  10. Hahner S, Allolio B. Therapeutic management of adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2009 Apr. 23(2):167-79. [Medline].

  11. Ahlawat SK, Jain S, Kumari S, Varma S, Sharma BK. Pheochromocytoma associated with pregnancy: case report and review of the literature. Obstet Gynecol Surv. 1999 Nov. 54(11):728-37. [Medline].

  12. Aono J, Mamiya K, Ueda W. Abrupt onset of adrenal crisis during routine preoperative examination in a patient with unknown Addison's disease. Anesthesiology. 1999 Jan. 90(1):313-4. [Medline].

  13. Arafah BM. Hypothalamic pituitary adrenal function during critical illness: limitations of current assessment methods. J Clin Endocrinol Metab. 2006 Oct. 91(10):3725-45. [Full Text].

  14. Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am. 2003 Jun. 32(2):367-83. [Medline].

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  17. Iga K, Hori K, Gen H. Deep negative T waves associated with reversible left ventricular dysfunction in acute adrenal crisis. Heart Vessels. 1992. 7(2):107-11. [Medline].

  18. Koo DJ, Jackman D, Chaudry IH, Wang P. Adrenal insufficiency during the late stage of polymicrobial sepsis. Crit Care Med. 2001 Mar. 29(3):618-22. [Medline].

  19. Kromah F, Tyroch A, McLean S, Hughes H, Flavin N, Lee S. Relative adrenal insufficiency in the critical care setting: debunking the classic myth. World J Surg. 2011 Aug. 35(8):1818-23. [Medline].

  20. Nicholson G, Burrin JM, Hall GM. Peri-operative steroid supplementation. Anaesthesia. 1998 Nov. 53(11):1091-104. [Medline].

  21. Obenour RA, Ross S. Adrenal Crisis. Hospital Formulary of the University of Tennessee Medical Center. 1999. [Full Text].

  22. Passmore JM Jr. Adrenal Cortex. Clinics in Critical Care Medicine. 1985. 97-134.

  23. Rao RH. Bilateral massive adrenal hemorrhage. Med Clin North Am. 1995 Jan. 79(1):107-29. [Medline].

  24. Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. 1989 Feb 1. 110(3):227-35. [Medline].

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  29. Zaloga GP. In: Zaloga G, MacGregor D, eds. The Critical Care Drug Handbook. New York, NY: Mosby Yearbook; 1991.

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Computed tomographic (CT) scans of the abdomen show normal adrenal glands several months before the onset of hemorrhage (upper panel) and enlarged adrenals 2 weeks after an acute episode of bilateral adrenal hemorrhage (lower panel). The attenuation of the adrenal glands, indicated by arrows, is increased after the acute event. Reproduced from Rao RH, Vagnucci AH, Amico JA: Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. Feb 1 1989;110(3):227-35 with permission from the journal.
Enlarged, dense, suprarenal masses
 
 
 
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