Addisonian crisis - Adrenal axis

Addisonian crisis

Definition

Acute presentation of complete adrenal failure.

Aetiology

Patients may already be diagnosed with Addison’s Disease or may present in crisis for the first time. Precipitating factors include trauma, illness or surgery. It may also be caused acutely by bilateral adrenal haemorrhage, due to meningococcal septicaemia (Waterhouse-Friderichsen syndrome) or anti-coagulant therapy. An Addisonian crisis may also occur on cessation of gluco-corticoid treatment including inhaled glucocorticoids in children.

Pathophysiology

In adrenal failure, there is no glucocorticoid response to stress. If exogenous high-dose steroids are not provided the condition is fatal.

Clinical features

The patient is ill with anorexia, vomiting and abdominal pain. This may suggest an acute abdomen. Signs include pyrexia and dehydration with tachycardia, hypotension (postural drop) decreased skin turgor and sunken eyes. Increased pigmentation may be noticed, especially in mouth, skin creases and pressure areas.

Investigations

Urgent cortisol and ACTH if possible.

U&Es (hyponatraemia, hyperkalaemia and hyperchloraemia).

Blood sugar monitoring to detect hypoglycaemia.

Definitive investigations should not delay treatment, steroids will not interfere with test results in the short-term.

Management

Immediate fluid resuscitation with 0.9% saline (and 5% dextrose if hypoglycaemia is present). Intravenous hydrocortisone and broad-spectrum antibiotics are given. Any underlying causes need to be identified and appropriately managed.

Prognosis

Has a high mortality.