eMedicine Specialties > Endocrinology > Adrenal Gland

Adrenal Crisis: Differential Diagnoses & Workup

Author: Lisa Kirkland, MD, FACP, CNSP, MSHA, Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital
Contributor Information and Disclosures

Updated: Aug 13, 2009

Differential Diagnoses

Septic Shock

Other Problems to Be Considered

Acute abdomen

Workup

Laboratory Studies

  • Serum chemistry: Abnormalities are present in as many as 56% of patients. Hyponatremia is common (although not diagnostic); hyperkalemia, metabolic acidosis, and hypoglycemia also may be present.
  • Serum cortisol: Less than 20 mcg/dL in severe stress or after ACTH stimulation is indicative of adrenal insufficiency.
  • ACTH test (diagnostic): Determine baseline serum cortisol, then administer ACTH 250 mcg intravenous push (IVP), and then draw serum cortisol 30 and 60 minutes after ACTH administration. An increase of less than 9 mcg/dL is considered diagnostic of adrenal insufficiency.
  • CBC: Anemia (mild and nonspecific), lymphocytosis, and eosinophilia (highly suggestive) may be present.
  • Serum thyroid levels: Assess for autoimmune, infiltrative, or multiple endocrine disorders.
  • Cultures: Perform blood and other cultures as clinically indicated. Infection is a common cause of acute adrenal crisis.

Imaging Studies

  • Chest radiography: Assess for tuberculosis, histoplasmosis, malignant disease, sarcoid, and lymphoma.
  • Abdominal CT scanning: Visualize adrenal glands for hemorrhage, atrophy, infiltrative disorders, and metastatic disease. Adrenal hemorrhage appears as hyperdense, bilaterally enlarged adrenal glands.

Other Tests

  • Electrocardiography
    • Prolongation of the QT interval can induce ventricular arrhythmias.
    • Deep negative T waves have been described in acute adrenal crisis.

Histologic Findings

Histology depends on the cause of the adrenal failure. In primary adrenocortical failure, histologic evidence of infection, infiltrative disease, or other condition may be demonstrated. Secondary adrenocortical insufficiency may cause atrophy of the adrenals or no histologic evidence at all, especially if due to exogenous steroid ingestion. Appearance of bilateral adrenal hemorrhage may be striking, as if bags of blood are replacing the glands.

More on Adrenal Crisis

Overview: Adrenal Crisis
Differential Diagnoses & Workup: Adrenal Crisis
Treatment & Medication: Adrenal Crisis
Follow-up: Adrenal Crisis
Multimedia: Adrenal Crisis
References
Further Reading
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References

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Keywords

adrenal crisis, adrenal insufficiency, cortisol, gland adrenal, adrenal, adrenal gland, cortisol levels, adrenal supplements, acute adrenal crisis, acute adrenal insufficiency, acute adrenocortical insufficiency, Addisonian crisis, adrenal apoplexy, aldosterone, primary adrenocortical insufficiency, secondary adrenocortical insufficiency, bilateral massive adrenal hemorrhage, BMAH, endocrine disorder

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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.

Medical Editor

David M Klachko, MBBCh, Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Missouri
David M Klachko, MBBCh 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

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.

 
 
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