Adrenal Crisis

Excerpt

Adrenal crisis, or Addisonian crisis, is a severe, life-threatening condition characterized by acute adrenal insufficiency. This condition has a substantial mortality rate of 0.5 per 100 patient years and remains a significant cause of death in individuals with adrenal insufficiency. Patients can experience rapid deterioration without timely intervention, resulting in fatal outcomes either at home or shortly after hospital admission.

This endocrine emergency arises when the production of cortisol, the primary glucocorticoid (GC) adrenal hormone, is inadequate either due to internal or external factors. Early recognition and immediate intervention are crucial for saving a patient's life and improving survival rates. Clinicians must distinguish between adrenal insufficiency and adrenal crisis, as the latter can be fatal if not treated promptly. Adrenal crisis refers to an episode of acute adrenal insufficiency (which may be primary, secondary, or tertiary) and is a medical emergency. However, chronic, stable primary adrenal insufficiency is called Addison disease, a condition controlled with long-term glucocorticoid therapy. Please see StatPearls' companion review, "Adrenal Insufficiency," for further details on Addison disease.

Adrenal crisis is characterized as an acute change in physiologic status that starts with nonspecific symptoms of fatigue, weakness, nausea, vomiting, abdominal pain, back pain, diarrhea, dizziness, hypotension, and syncope, that quickly progresses to obtundation, metabolic encephalopathy, and shock. Despite the well-described characteristics of this condition, its recognition can be challenging, resulting in delayed treatment initiation and increased morbidity and mortality rates. Essential measures in preventing adrenal crises include educating patients and their families about "sick day" rules, by which they should increase hydrocortisone to 2 to 3 times the normal glucocorticoid dose for 2 to 3 days for minor illnesses and more for major illnesses. Clinicians should also ensure the availability of intramuscular hydrocortisone at home.

The ongoing debate among experts in the field has led to a lack of consensus on the definition of adrenal crisis. Several expert reviews have tried to establish definitions of adrenal crisis. Among the numerous descriptions available for this condition, a recent study by Rushworth et al in 2019 posited that an adrenal crisis is defined as an acute deterioration in health status associated with either of the following conditions:

1. Absolute hypotension with a systolic blood pressure <100 mm Hg.

2. Relative hypotension with a systolic blood pressure at least 20 mm Hg lower than the patient's usual baseline

Typically, these features should improve and resolve within 1 to 2 hours after administering parenteral glucocorticoids, marked by a significant reduction in hypotension within the first hour. Furthermore, there should be a gradual improvement in patients' clinical symptoms over the subsequent 2 hours.