Acute adrenal crisis

Alternative Names

Adrenal crisis; Addisonian crisis; Acute adrenal insufficiency

Definition

Acute adrenal crisis is a life-threatening condition that occurs when there is not enough cortisol. This is a hormone produced by the adrenal glands.

Causes

The adrenal glands are located just above the kidneys. The adrenal gland consists of two parts. The outer portion, called the cortex, produces cortisol. This is an important hormone for controlling blood pressure. The inner portion, called the medulla, produces the hormone adrenaline (also called epinephrine). Both cortisol and adrenaline are released in response to stress.

Cortisol production is regulated by the pituitary gland. This is a small gland behind the nose and under the brain. The pituitary gland releases adrenocorticotropic hormone (ACTH). This is a hormone that causes the adrenal glands to release cortisol.

Adrenaline production is regulated by nerves coming from the brain and spinal cord and by circulating hormones.

Adrenal crisis occurs when:

• The adrenal gland is damaged due to, for example, Addison disease or other adrenal gland disease, surgery
• The pituitary gland is injured and cannot release ACTH
• Adrenal insufficiency is not properly treated

Risk factors for adrenal crisis include:

• Dehydration
• Infection and other physical stress
• Injury to the adrenal or pituitary gland
• Stopping treatment too suddenly with glucocorticoid medications such as prednisone or hydrocortisone
• Surgery
• Trauma

Symptoms

Symptoms of adrenal crisis can include any of the following:

• Abdominal pain
• Confusion or coma
• Dehydration
• Dizziness or light-headedness
• Fatigue
• Flank pain
• Headache
• High fever
• Loss of appetite
• Loss of consciousness
• Low blood pressure
• Nausea
• Profound weakness
• Rapid heart rate
• Rapid respiratory rate (see tachypnea)
• Slow, sluggish movement
• Unusual and excessive sweating on face or palms
• Vomiting

Exams and Tests

Tests that may be ordered to help diagnose acute adrenal crisis include:

• ACTH (cosyntropin) stimulation test
• Cortisol level
• Blood sugar
• Serum potassium
• Serum sodium
• Serum pH

Treatment

In adrenal crisis, patients need an immediate injection of hydrocortisone through a vein (intravenous) or muscle (intramuscular). You may receive intravenous fluids if you have low blood pressure.

You will need to go to the hospital for treatment and monitoring. If infection or another medical problem caused the crisis, you may need additional treatment.

Outlook (Prognosis)

Shock may occur if treatment is not provided early, and it can be life-threatening.

Possible Complications

• Coma
• Seizures
• Shock
• Hypoglycemia

When to Contact a Medical Professional

Call your health care provider if you have Addison disease and are unable to take your glucocorticoid medicine for any reason.

Go to the emergency room or call the local emergency number (such as 911) if you develop symptoms of acute adrenal crisis.

If you have Addison disease, you may be told to increase the dosage of your glucocorticoid medicine if you are very ill or before having surgery.

Prevention

If you have Addison disease, learn to recognize signs of potential stress that may cause an acute adrenal crisis. If you have been instructed by your doctor, be prepared to give yourself an emergency shot of glucocorticoid or to increase your dosage of oral glucocorticoid medication in times of stress.

Always carry medical ID (card, bracelet, or necklace) that says you have adrenal insufficiency. The ID should also say the type of medicine and dosage you need in case of an emergency.

Never miss taking your medicines.

References

Chaker AJ, Vaidya B. Addison disease in adults: diagnosis and management. Am J Med. 2010;123:409-413.

Stewart PM, Krone NP. The adrenal cortex. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 12th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 15.