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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 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]


See the list below:

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


See the list below:

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

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.

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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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