Adrenal Crisis Workup
- Author: Lisa Kirkland, MD, FACP, FCCM, MSHA; Chief Editor: George T Griffing, MD more...
See the list below:
- 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. However, the absence of laboratory abnormalities does not exclude the diagnosis of adrenal crisis.
- 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.
See the list below:
- Chest radiography: Assess for tuberculosis, histoplasmosis, malignant disease, sarcoid, and lymphoma.
- Abdominal CT scanning: Visualize adrenal glands for hemorrhage (as in the image below), atrophy, infiltrative disorders, and metastatic disease. Adrenal hemorrhage appears as hyperdense, bilaterally enlarged adrenal glands.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.
See the list below:
- Prolongation of the QT interval can induce ventricular arrhythmias.
- Deep negative T waves have been described in acute adrenal crisis.
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.
Loriaux DL, Fleseriu M. Relative adrenal insufficiency. Curr Opin Endocrinol Diabetes Obes. 2009 Aug 3. [Medline].
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].
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].
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].
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].
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].
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].
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].
Arlt W. The approach to the adult with newly diagnosed adrenal insufficiency. J Clin Endocrinol Metab. 2009 Apr. 94(4):1059-67. [Medline].
Hahner S, Allolio B. Therapeutic management of adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2009 Apr. 23(2):167-79. [Medline].
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].
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].
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].
Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am. 2003 Jun. 32(2):367-83. [Medline].
Chin R. Adrenal crisis. Crit Care Clin. 1991 Jan. 7(1):23-42. [Medline].
Cronin CC, Callaghan N, Kearney PJ, et al. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. 1997 Feb 24. 157(4):456-8. [Medline].
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].
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].
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].
Nicholson G, Burrin JM, Hall GM. Peri-operative steroid supplementation. Anaesthesia. 1998 Nov. 53(11):1091-104. [Medline].
Obenour RA, Ross S. Adrenal Crisis. Hospital Formulary of the University of Tennessee Medical Center. 1999. [Full Text].
Passmore JM Jr. Adrenal Cortex. Clinics in Critical Care Medicine. 1985. 97-134.
Rao RH. Bilateral massive adrenal hemorrhage. Med Clin North Am. 1995 Jan. 79(1):107-29. [Medline].
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].
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. 2001 Feb. 29(2):310-6. [Medline].
Vella A, Nippoldt TB, Morris JC 3rd. Adrenal hemorrhage: a 25-year experience at the Mayo Clinic. Mayo Clin Proc. 2001 Feb. 76(2):161-8. [Medline].
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.
Xarli VP, Steele AA, Davis PJ, et al. Adrenal hemorrhage in the adult. Medicine (Baltimore). 1978 May. 57(3):211-21. [Medline].
Zaloga GP. In: Zaloga G, MacGregor D, eds. The Critical Care Drug Handbook. New York, NY: Mosby Yearbook; 1991.