Adrenal Crisis in Emergency Medicine Clinical Presentation

Updated: Oct 10, 2022
  • Author: Kevin M Klauer, DO, EJD, FACEP; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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The following are important elements in the history of patients with adrenal crisis or adrenal insufficiency [5, 6] :

  • Weakness (99%)

  • Pigmentation of skin (98%)

  • Weight loss (97%)

  • Abdominal pain (34%)

  • Salt craving (22%)

  • Diarrhea (20%)

  • Constipation (19%)

  • Syncope (16%)

  • Vitiligo (9%)

A cross-sectional study by Kawahara et al found that in adult patients presenting to a Japanese hospital’s emergency department with hypoglycemia, adrenal insufficiency was the cause in 6.1% of them. Adrenal insufficiency was the third most prominent etiology for hypoglycemia among hypoglycemic people aged 18 years or older who visited the emergency department, with antidiabetes medications (73.7%) and alcohol abuse (6.6%) being the first and second most frequent causes, respectively. The investigators also reported that hyponatremia, hypotension, and eosinophilia were found more often in association with adrenal insufficiency than with other causes of hypoglycemia. They recommended that in patients with protracted hypoglycemia of unknown etiology who also have hyponatremia, hypotension, and/or eosinophilia, a rapid adrenocorticotropic hormone (ACTH) loading test be used to evaluate adrenal function. [15]



Physical findings in patients with adrenal insufficiency are subtle and nonspecific.

  • Patients with mineralocorticoid insufficiency may show signs of sodium and volume depletion (eg, orthostatic hypotension, tachycardia).

  • Evidence of hyperpigmentation is observed, particularly in areas exposed to the sun or areas subject to friction or pressure.



Causes and related conditions include the following:

  • Surgery

  • Anesthesia (eg, etomidate)

  • Volume loss (unmasks, unless there is bleeding in the adrenals)

  • Trauma

  • Asthma (steroid withdrawal)

  • Hypothermia (a consequence, not cause)

  • Alcohol (not well substantiated)

  • Myocardial infarction (unmasks but does not cause)

  • Fever/infection: In the aforementioned study from the Netherlands, Smans et al found that among patients with adrenal insufficiency, the existence of comorbidity is the most important risk factor for adrenal crisis, with infections being the most common precipitating factors [11]

  • Hypoglycemia (more likely a consequence rather than cause)

  • Pain (unmasks, but does not cause)

  • Psychoses or depression (associated with, but not causative)

  • Exogenous steroid withdrawal