Medicine

July 26th, 2020

Adrenal Crisis

Clinicals - History

Introduction

Adrenal crisis does not have a universally agreed-on definition or criteria; what is agreed is that it represents the acute onset or worsening of adrenal insufficiency.

Nausea and vomiting

Nausea and vomiting are commonly reported symptoms, although in some cases they may indicate an underlying gastroenteritis, rather than being due to the crisis itself.

Muscle cramps

Muscle cramps are typically an early herald of an impending crisis. These are thought to be due to electrolyte disturbances.

Rapid symptom progression

Adrenal crises tend to progress rapidly, as the onset triggers a vicious cycle of increasing stress. Studies have shown a delay of only 24 hours from first symptoms to a full-blown crisis.

Preceding constitutional symptoms

There may be a preceding history of fatigue, lethargy and weight loss. These are due to the chronic glucocorticoid deficiency secondary to underlying undiagnosed adrenal insufficiency.

Presence of trigger factors

Sepsis is the most common trigger of adrenal crisis; other triggers include trauma, surgery, pregnancy, heat, and psychological stress, and poor compliance with glucocorticoid therapy.


Note that in 6% to 12% of patients, a trigger cannot be be identified.

Known or underlying adrenal insufficiency

Around half of patients have a known history of adrenal insufficiency. This may be primary insufficiency due to adrenal injury via autoimmune disease, tuberculosis, infection, or surgery; or secondary insufficiency due to pituitary failure, e.g. after Sheehan's syndrome.

Previous glucocorticoid therapy

Prolonged glucocorticoid therapy (i.e. doses equivalent to ≥5mg prednisolone over ≥4 weeks) leads to suppression of endogenous steroid production.


This may occur in patients with asthma, chronic obstructive pulmonary disease (COPD) and chronic autoimmune conditions.

Medications

Medications that can precipitate an adrenal crisis include adrenostatic drugs such as etomidate, and ketoconazole; and agents that increase cortisol metabolism, e.g., barbiturates, rifampin, and mitotane.

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