Adrenal Crisis Clinical Presentation

  • Author: Lisa Kirkland, MD, FACP, CNSP, MSHA; Chief Editor: George T Griffing, MD   more...
 
Updated: Mar 8, 2010
 

History

  • 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[5] (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.[6] 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.
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Physical

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

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

Lisa Kirkland, MD, FACP, CNSP, MSHA  Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, Endocrine Society, Missouri State Medical Association, and Sigma Xi

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Don S Schalch, MD  Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Mark Cooper, MBBS, PhD, FRACP  Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor 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, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

References

  1. Loriaux DL, Fleseriu M. Relative adrenal insufficiency. Curr Opin Endocrinol Diabetes Obes. Aug 3 2009;[Medline].

  2. White K, Arlt W. Adrenal crisis in treated Addison's disease: a predictable but under-managed event. Eur J Endocrinol. Jan 2010;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. Mar 2010;162(3):597-602. [Medline].

  4. 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. Aug 21 2002;288(7):862-71. [Medline]. [Full Text].

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

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

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

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

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

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

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

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

  13. Chin R. Adrenal crisis. Crit Care Clin. Jan 1991;7(1):23-42. [Medline].

  14. Cronin CC, Callaghan N, Kearney PJ, et al. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. Feb 24 1997;157(4):456-8. [Medline].

  15. 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].

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

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

  18. Obenour RA, Ross S. Adrenal Crisis. Hospital Formulary of the University of Tennessee Medical Center [serial online]. 1999;Available at http://www.cushings-help.com/adrenal-crisis.htm.

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

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

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

  22. Schroeder S, Wichers M, Klingmuller D, et al. The hypothalamic-pituitary-adrenal axis of patients with severe sepsis: altered response to corticotropin-releasing hormone. Crit Care Med. Feb 2001;29(2):310-6. [Medline].

  23. Vella A, Nippoldt TB, Morris JC 3rd. Adrenal hemorrhage: a 25-year experience at the Mayo Clinic. Mayo Clin Proc. Feb 2001;76(2):161-8. [Medline].

  24. Williams GH, Dluhy RG. Disease of the Adrenal Cortex. In: Braunwald E, Fauci AS, Kasper DL, eds. Harrison's Principles of Internal Medicine. 13th ed. New York, NY: McGraw-Hill; 1994:1953-76.

  25. Xarli VP, Steele AA, Davis PJ, et al. Adrenal hemorrhage in the adult. Medicine (Baltimore). May 1978;57(3):211-21. [Medline].

  26. 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
Table 1
TimingHydrocortisoneHydrocortisoneFludrocortisone
Routine daily…20 mg PO at 8 am



10 mg PO at 4 pm



0.1 mg PO at 8 am
Day of operation10 mg/h continuous infusion……
Postoperative day 15-7.5 mg/h continuous infusion……
Postoperative day 22.5-5 mg/h continuous infusion……
Postoperative day 32.5-5 mg/h continuous infusion or40 mg PO at 8 am



20 mg PO at 4 pm



0.1 mg PO at 8 am
Postoperative day 42.5-5 mg/h continuous infusion or40 mg PO at 8 am



20 mg PO at 4 pm



0.1 mg PO at 8 am
Postoperative day 5…40 mg PO at 8 am



20 mg PO at 4 pm



0.1 mg PO at 8 am
Postoperative day 6…20 mg PO at 8 am



20 mg PO at 4 pm



0.1 mg PO at 8 am
Postoperative day 7…20 mg PO at 8 am



10 mg PO at 4 pm



0.1 mg PO at 8 am
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