Addisonian Crisis (Adrenal Crisis)

Addisonian crisis is a rare occurrence, characterized by a sudden onset insufficiency in the production of cortisol and aldosterone by the adrenal glands. It may be induced by an acute relapse episode of chronic adrenal insufficiency, usually preceded by infections, surgical procedures or traumatization of the adrenal glands and constitutes a medical emergency, since failure to treat the episode can endanger the life of a patient. Symptoms include fatigue, loss of consciousness, tachycardia, dizziness, tachypnea and a variety of other clinical manifestations.

Addisonian Crisis originates from this process: endocrine.

Presentation

An Addisonian crisis is induced by an acute failure of the adrenal glands to produce aldosterone and cortisol; if left untreated, it can put the patient's life at a great risk [1] [2] [3]. An Addisonian crisis tends to produce a multitude of symptoms, which are non-specific, but do indicate a severe underlying pathology [4] [5] [6]. Patients may be febrile, in a disoriented or comatose state, dizzy and display a tendency towards slow, uncoordinated movement. Nausea, vomiting, headache, and fatigue are also common symptoms alongside profound sweating that is localized on the palmar surface of the hands and face. Symptoms related to the cardiovascular system are also elicited, such as tachycardia and hypotension, while the respiratory rate may also be elevated. Lastly, pain may be experienced in the region of the abdomen or flanks.

With regard to the signs exhibited by a patient affected by Addisonian crisis, localized hyperpigmentation may be evident in areas of the skin that are subjected to prolonged exposure to sunlight.

cardiovascular
Hypotension
  • Classically it presents as severe hypotension refractory to IV fluids and vasopressors.[coreem.net]
  • - confusion - nausea - vomiting - diarrhea - vague abdominal pain Hypotension may lead to shock.[signsandsyndromes.com]
  • No hypotension or other marked symptoms had been demonstrated since the supplemental therapy of cortisol was started.[anesthesiology.pubs.asahq.org]
  • , balance the effects of insulin helps maintain bp, water/salt balance secondary to an illness or a stressful event; becomes life threatening acute deficiency in cortisol production and this results in circulatory collapse and electrolyte imbalances hypotension[quizlet.com]
  • , refractory shock, poor response to inotropes/pressors fever confusion CHRONIC ADRENAL INSUFFICIENCY GENERAL: weight loss, arthalgia, myalgia CNS: fatigue, anorexia, mood change CVS: postural hypotension, syncope, salt craving SKIN: pigmentation, vitiligo[lifeinthefastlane.com]
Orthostatic Hypotension
  • hypotension ( G90.3 ) orthostatic hypotension ( I95.1 ) postprocedural shock ( T81.1- ) psychogenic syncope ( F48.8 ) shock NOS ( R57.9 ) shock complicating or following abortion or ectopic or molar pregnancy ( O00 - O07 , O08.3 ) shock complicating[icd10data.com]
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  • gastrointestinal
    Vomiting
    • During the next week her vomiting worsened.[ispub.com]
    • I have had a crisis go from being okay to vomitting and not being able to move in about 15 to 20 minutes and ambulances called and being carried to the ambulance by firemen.[drugs.com]
    • If unable to retain medication due to vomiting, notify the health care provider.[uclahealth.org]
    • If you can't keep the medication down because of vomiting, take the medication by injection, as directed by your medical team.[mountnittany.org]
    • Sophie had begun vomiting and having diarrhea that day.[encinavet.com]
    Nausea
    • You have to follow up with about three of them a day given by a doctor, replace the fluids and minerals including sodium into your body and also if there is nausea or vomiting that needs to be controlled.[drugs.com]
    • Patients may experience lightheadedness or dizziness, weakness, sweating, abdominal pain, nausea and vomiting, or even loss of consciousness.[uclahealth.org]
    • Warning signs include: severe nausea headache dizziness extreme weakness chills or fever confusion.[addisons.org.uk]
    • Addison , who described it] Addison's disease A condition caused by undersecretion of adrenal steroid hormones, resulting in weakness, nausea, low circulation, and bronzing of the skin.[thefreedictionary.com]
    • […] symptoms usually develop slowly, often over several months, and may include: Extreme fatigue Weight loss and decreased appetite Darkening of your skin (hyperpigmentation) Low blood pressure, even fainting Salt craving Low blood sugar (hypoglycemia) Nausea[mayoclinic.org]
    Abdominal Pain
    • Patients may experience lightheadedness or dizziness, weakness, sweating, abdominal pain, nausea and vomiting, or even loss of consciousness.[uclahealth.org]
    • He denied chills, diarrhea, abdominal pain, respiratory or urinary symptoms.[ispub.com]
    • It is equally important in all persons with chronic abdominal pain for whom surgery is considered necessary FULL TEXT[annals.org]
    • […] slowly, often over several months, and may include: Extreme fatigue Weight loss and decreased appetite Darkening of your skin (hyperpigmentation) Low blood pressure, even fainting Salt craving Low blood sugar (hypoglycemia) Nausea, diarrhea or vomiting Abdominal[mayoclinic.org]
    • pain Hypotension may lead to shock.[signsandsyndromes.com]
    Loss of Appetite
    • […] of appetite Signs and tests: An ACTH (cortrosyn) stimulation test shows low cortisol.[uclahealth.org]
    • When to seek medical care Call your doctor right away if you have any of the following: Tiredness or weakness Loss of appetite or weight loss Dizziness when you stand up after sitting or lying down Muscle aches Nausea, vomiting, or diarrhea Sharp pain[mountnittany.org]
    • Acute adrenal crisis (Addisonian Crisis / Acute Adrenal Insufficiency) Addison’s Disease Depression Fatigue Nausea and Vomiting Abdominal pain Hair loss Decreased appetite Headache High-grade fever Rapid heartbeat Low Blood Pressure (Hypotension) Dehydration[mymed.com]
    • The syndrome usually starts with nausea, vomiting, loss of appetite, and diarrhea with unspecific abdominal cramps.[news-medical.net]
    • Symptoms include: Abdominal pain Confusion or coma Darkening of the skin Dehydration Dizziness or light-headedness Fatigue Flank pain Headache High fever Joint pain Loss of appetite Loss of consciousness Low blood pressure Nausea Profound weakness Rapid[drugs.com]
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  • Entire body system
    Fever
    • […] hypovolemic shock, profound hypoglycemia, confusion, altered mental status, ventricular dysrhythmias, GI (N/V, diarrhea, anorexia, cramps), hyperpigmentation of the skin pts usually present with non specific symptoms (weakness, fatigue, sometimes a fever[quizlet.com]
    • Stress and the HPA Axis Clinical Presentation Variable and non-specific complaints – weakness, confusion, fever, nausea, vomiting, abdominal pain Shock and fever can be only signs Common precipitants – surgery, infection, burn, sepsis, trauma, metabolic[coreem.net]
    • Warning signs include: severe nausea headache dizziness extreme weakness chills or fever confusion.[addisons.org.uk]
    • These include: - hypotension (particularly postural) - tachycardia (rapid heart rate) - dehydration - hyponatremia (reduced serum sodium levels) - hyperkalemia (elevated serum potassium levels) - hypoglycemia (low blood sugar levels) - fever - weakness[signsandsyndromes.com]
    Hypothermia
    • On presentation, the patient will have mild hypothermia, hypoglycemia, and hypotension.[emsimcases.com]
    • […] known primary or secondary adrenocortical insufficiency AIDS Invasive or infiltrative disorders Tuberculosis Physical: Unexplained shock, usually refractory to fluid and pressor resuscitation Nausea, vomiting, abdominal or flank pain Hyperthermia or hypothermia[addisons-help.com]
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  • Workup

    In order to evaluate a patient with a suspected Addisonian crisis, various laboratory tests should be performed. A complete blood count, serum electrolyte levels, BUN and creatinine levels, cortisol and adrenocorticotropic hormone (ACTH) levels and calcium levels in the blood should be measured and the thyroid function should also be assessed [7].

    As far as imaging modalities are concerned, computerized tomography (CT) can be employed to identify pathology of the adrenal glands, such as trauma, calcification caused by tuberculosis or malignancy. A CT scan of the head can also detect pituitary abnormalities that may secondarily cause the insufficient production of adrenal hormones and lead to an Addisonian crisis.

    Lastly, the ACTH stimulation test is another useful tool that can help to evaluate the functionality of the adrenal glands by measuring their response to the administration of ACTH. After serum cortisol and ACTH levels have been obtained, 0.25 mg of tetracosactide (cosyntropin) is administered. It is a synthetic ACTH product [8] [9]. The substance is administered intravenously or intramuscularly and serum cortisol levels are tested half an hour and six hours after the administration. Should serum cortisol concentration fail to rise after the administration of synthetic ACTH, adrenal insufficiency is established as the diagnosis, always after the careful evaluation of the other parameters. Treatment should not be at any cost delayed in order for the ACTH stimulation test to be performed, as the reliability of the results is unaffected by the administration of dexamethasone. Cortisol levels can also be measured in the urine over a 24-hour period, but this test is only employed in cases where there is no immediate threat to the patient's life.

    Laboratory

    Serum
    Hyponatremia
    • Preparation of such a patient for surgery should include treatment of hypovolemia, hyperkalemia, and hyponatremia .[openanesthesia.org]
    • […] electrolytes, neuro checks (hypoperfusion, hypoglycemia, hyponatremia), daily weights, monitor for fluid overload provide a safe environment, teamwork and communication, minimize stress, nutritional intake (need to add salt!)[quizlet.com]
    • The hyponatremia was also mild (at least for the control blood sample).[anesthesiology.pubs.asahq.org]
    • Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia.[emsimcases.com]
    • An insulin stress test should cause hypoglycemia and a spike in both plasma cortisol and serum growth hormone within 1-2 hours. hypoglycemia hyponatremia, hyperkalemia return to top Differential Diagnosis return to top Treatments Hydrocortisone is the[sharinginhealth.ca]
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  • Imaging

    X-ray
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  • Treatment

    Prognosis

    Complications

    Paralytic Ileus
    • Adrenal crisis with paralytic ileus was diagnosed.[ispub.com]
    Ileus
    • Adrenal crisis with paralytic ileus was diagnosed.[ispub.com]
    Fever
    • […] hypovolemic shock, profound hypoglycemia, confusion, altered mental status, ventricular dysrhythmias, GI (N/V, diarrhea, anorexia, cramps), hyperpigmentation of the skin pts usually present with non specific symptoms (weakness, fatigue, sometimes a fever[quizlet.com]
    • Stress and the HPA Axis Clinical Presentation Variable and non-specific complaints – weakness, confusion, fever, nausea, vomiting, abdominal pain Shock and fever can be only signs Common precipitants – surgery, infection, burn, sepsis, trauma, metabolic[coreem.net]
    • Warning signs include: severe nausea headache dizziness extreme weakness chills or fever confusion.[addisons.org.uk]
    • These include: - hypotension (particularly postural) - tachycardia (rapid heart rate) - dehydration - hyponatremia (reduced serum sodium levels) - hyperkalemia (elevated serum potassium levels) - hypoglycemia (low blood sugar levels) - fever - weakness[signsandsyndromes.com]
    Shock
    • ( R57.0 ) carotid sinus syncope ( G90.01 ) heat syncope ( T67.1 ) neurocirculatory asthenia ( F45.8 ) neurogenic orthostatic hypotension ( G90.3 ) orthostatic hypotension ( I95.1 ) postprocedural shock ( T81.1- ) psychogenic syncope ( F48.8 ) shock NOS[icd10data.com]
    • Sort out the shock .[medrevise.co.uk]
    • Why it Matters While adrenal crisis is a relatively rare presentation, shock is not.[emsimcases.com]
    • In contrast, an acute adrenal crisis can present with vomiting, abdominal pain, and hypovolemic shock.[addisons-help.com]
    • "Effect of Treatment With Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients With Septic Shock".[en.wikipedia.org]
    Hypoglycemia
    • Treat severe hyperglycemia with 1-2 gm/kg of D50 Consider infusion of D5NS for continued hypoglycemia Check FS glucose Q1-2 hours to ensure improving hypoglycemia Hypotension IVF bolus of 30 cc/kg Consider using D5NS for resuscitation if the patient[coreem.net]
    • […] balance secondary to an illness or a stressful event; becomes life threatening acute deficiency in cortisol production and this results in circulatory collapse and electrolyte imbalances hypotension, tachycardia, dehydration, hypovolemic shock, profound hypoglycemia[quizlet.com]
    • An insulin stress test should cause hypoglycemia and a spike in both plasma cortisol and serum growth hormone within 1-2 hours. hypoglycemia hyponatremia, hyperkalemia return to top Differential Diagnosis return to top Treatments Hydrocortisone is the[sharinginhealth.ca]
    • On presentation, the patient will have mild hypothermia, hypoglycemia, and hypotension.[emsimcases.com]
    • Signs and symptoms include low blood pressure, nausea and vomiting, syncope, hypoglycemia, hyponatremia, hyperkalemia, a metabolic acidosis, lethergy, confusion, and convulsions.[openanesthesia.org]
    Acidosis
    • Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia.[emsimcases.com]
    • Signs and symptoms include low blood pressure, nausea and vomiting, syncope, hypoglycemia, hyponatremia, hyperkalemia, a metabolic acidosis, lethergy, confusion, and convulsions.[openanesthesia.org]
    • Pituitary apoplexy – infarction or hemorrhage of tumor Chronic steroid therapy (suppresses HPA axis) Tumors, granulomas Diagnostic Studies : CBC, BMP, VBG, fingerstick /- EKG Hypoglycemia Hyponatremia ( Hyperkalemia ( 5mEq/L) Non-anion gap metabolic acidosis[coreem.net]
    • […] to loss of androgens Crisis: hypotension, shock dehydration fever Excess: edema (excess G) return to top Investigations lab investigations diagnostic imaging Lab Investigations hyponatremia and salt craving (M) hyperkalemia (mild) hypercalcemia mild acidosis[sharinginhealth.ca]
    • Check pH, electrolytes and glucose frequently Blood gas and BGL hourly x 2 hours; then 2-4 hourly once normoglycaemic and acidosis correcting.[rch.org.au]
    Metabolic Acidosis
    • Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia.[emsimcases.com]
    • Signs and symptoms include low blood pressure, nausea and vomiting, syncope, hypoglycemia, hyponatremia, hyperkalemia, a metabolic acidosis, lethergy, confusion, and convulsions.[openanesthesia.org]
    • acidosis Low bicarbonate (15-20mEq/L) Elevated BUN and creatinine Management Steroid Replacement Initial Dose Hydrocortisone 100mg IV preferred but can be given IM if necessary Stress dose hydrocortisone has mineralocorticoid activity (20mg 0.1mg Florinef[coreem.net]
    • Metabolic acidosis exacerbates hyperkalemia, as H ions move intracellularly and are exchanged for K ions in the extracellular fluid.[veterinarycalendar.dvm360.com]
    • Pathophysiologically, there is significant hyponatremia and hyperkalemia, often associated with metabolic acidosis, hypoglycemia, and (every so often) hypercalcemia.[news-medical.net]
    Hypotension
    • Classically it presents as severe hypotension refractory to IV fluids and vasopressors.[coreem.net]
    • - confusion - nausea - vomiting - diarrhea - vague abdominal pain Hypotension may lead to shock.[signsandsyndromes.com]
    • No hypotension or other marked symptoms had been demonstrated since the supplemental therapy of cortisol was started.[anesthesiology.pubs.asahq.org]
    • , balance the effects of insulin helps maintain bp, water/salt balance secondary to an illness or a stressful event; becomes life threatening acute deficiency in cortisol production and this results in circulatory collapse and electrolyte imbalances hypotension[quizlet.com]
    • , refractory shock, poor response to inotropes/pressors fever confusion CHRONIC ADRENAL INSUFFICIENCY GENERAL: weight loss, arthalgia, myalgia CNS: fatigue, anorexia, mood change CVS: postural hypotension, syncope, salt craving SKIN: pigmentation, vitiligo[lifeinthefastlane.com]
    Hyperkalemia
    • Preparation of such a patient for surgery should include treatment of hypovolemia, hyperkalemia, and hyponatremia .[openanesthesia.org]
    • The team will need to treat the hyperkalemia and initiate hydrocortisone therapy.[emsimcases.com]
    • Usually normalized w/ fluids and steroid replacement Monitor K Q2-3 hours as may fall during initial rehydration See Core EM post on Hyperkalemia for further management Prevention Triple PO steroids if known susceptibility to crisis in setting of physiologic[coreem.net]
    • , hypercalcemia, azotemia (nitrogen), high creatinine sudden withdrawal of glucocorticoids, extress stress, trauma, sepsis, TB, adrenal hemorrhage, autoimmune watch VS (extreme hypotension), tele monitoring (hyperkalemia, hyponatremia), electrolytes,[quizlet.com]
    • Use of calcium, insulin, and bicarbonate is reserved for life-threatening hyperkalemia; appropriate fluid therapy is the cornerstone of treating hypoadrenocorticism and hyperkalemia.[vetfolio.com]
    Hyponatremia
    • Preparation of such a patient for surgery should include treatment of hypovolemia, hyperkalemia, and hyponatremia .[openanesthesia.org]
    • […] electrolytes, neuro checks (hypoperfusion, hypoglycemia, hyponatremia), daily weights, monitor for fluid overload provide a safe environment, teamwork and communication, minimize stress, nutritional intake (need to add salt!)[quizlet.com]
    • The hyponatremia was also mild (at least for the control blood sample).[anesthesiology.pubs.asahq.org]
    • Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia.[emsimcases.com]
    • An insulin stress test should cause hypoglycemia and a spike in both plasma cortisol and serum growth hormone within 1-2 hours. hypoglycemia hyponatremia, hyperkalemia return to top Differential Diagnosis return to top Treatments Hydrocortisone is the[sharinginhealth.ca]
    Hypovolemic Shock
    • […] maintain bp, water/salt balance secondary to an illness or a stressful event; becomes life threatening acute deficiency in cortisol production and this results in circulatory collapse and electrolyte imbalances hypotension, tachycardia, dehydration, hypovolemic[quizlet.com]
    • This can cause patients to go into hypovolemic shock, which results in rapid and shallow breathing combined with an extremely fast but weak heart rate.[livestrong.com]
    • In contrast, an acute adrenal crisis can present with vomiting, abdominal pain, and hypovolemic shock.[addisons-help.com]
    • This patient with bladder cancer metastatic to adrenal gland presented as acute adrenal insufficiency with hypovolemic shock.[ispub.com]
    Adrenocortical Insufficiency
    • , Insufficiency, Primary Adrenocortical , Primary Adrenal Insufficiency , Primary Adrenocortical Insufficiencies , Primary Adrenocortical Insufficiency , Primary Hypoadrenalism , Adrenal Insufficiency, Primary , Adrenocortical Insufficiencies, Primary[fpnotebook.com]
    • Adrenal Crisis Adrenal Crisis excerpt Synonyms and related keywords: acute adrenal crisis, acute adrenocortical insufficiency, acute adrenal insufficiency, addisonian crisis, adrenal apoplexy, cortisol, aldosterone, primary adrenocortical insufficiency[addisons-help.com]
    • insufficiency E27.2 Addisonian crisis E27.3 Drug-induced adrenocortical insufficiency E27.4 Other and unspecified adrenocortical insufficiency E27.40 Unspecified adrenocortical insufficiency E27.49 Other adrenocortical insufficiency E27.5 Adrenomedullary[icd10data.com]
    • Secondary adrenocortical insufficiency is relatively common.[emedicine.medscape.com]
    • Secondary adrenocortical insufficiency occurs when exogenous steroids have suppressed the hypothalamic-pituitary-adrenal (HPA) axis.[emedicine.medscape.com]
    Hypothermia
    • On presentation, the patient will have mild hypothermia, hypoglycemia, and hypotension.[emsimcases.com]
    • […] known primary or secondary adrenocortical insufficiency AIDS Invasive or infiltrative disorders Tuberculosis Physical: Unexplained shock, usually refractory to fluid and pressor resuscitation Nausea, vomiting, abdominal or flank pain Hyperthermia or hypothermia[addisons-help.com]

    Etiology

    Causes

    Metabolic Acidosis
    • Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia.[emsimcases.com]
    • Signs and symptoms include low blood pressure, nausea and vomiting, syncope, hypoglycemia, hyponatremia, hyperkalemia, a metabolic acidosis, lethergy, confusion, and convulsions.[openanesthesia.org]
    • acidosis Low bicarbonate (15-20mEq/L) Elevated BUN and creatinine Management Steroid Replacement Initial Dose Hydrocortisone 100mg IV preferred but can be given IM if necessary Stress dose hydrocortisone has mineralocorticoid activity (20mg 0.1mg Florinef[coreem.net]
    • Metabolic acidosis exacerbates hyperkalemia, as H ions move intracellularly and are exchanged for K ions in the extracellular fluid.[veterinarycalendar.dvm360.com]
    • Pathophysiologically, there is significant hyponatremia and hyperkalemia, often associated with metabolic acidosis, hypoglycemia, and (every so often) hypercalcemia.[news-medical.net]

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

    Self-assessment

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    References

    1. Sunil P, A Shrestha, D Maksey, et al. Addisonian Crisis Precipitated By Thyroxine Therapy In A Patient With Type 2 Autoimmune Polyglandular Syndrome.Journal of Chitwan Medical College 2013; 3(4); 54-56.
    2. Husebye ES, Allolio B, Arlt W, et al; Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med. 2014 Feb;275(2):104-15.
    3. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency - the need for new prevention strategies. Eur J Endocrinol. 2010 Mar;162(3):597-602.
    4. Husebye ES, Allolio B, Arlt W, et al; Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med. 2014 Feb;275(2):104-15.
    5. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010 Mar; 162(3):597-602.
    6. Ahi S, Esmaeilzadeh M, Kayvanpour E, Sedaghat-Hamedani F, Samadanifard SH. A bulking agent may lead to adrenal insufficiency crisis: a case report. Acta Med Iran. 2011; 49(10):688-9.
    7. Marik PE, Pastores SM, Annane D, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008 Jun; 36(6):1937-49.
    8. Dorin RI, Qualls CR, Crapo LM. Diagnosis of adrenal insufficiency. Ann. Intern. Med. 2003;139 (3): 194–204.
    9. Oelkers W, Diederich S, Bahr V. Diagnosis and therapy surveillance in Addison's disease: rapid adrenocorticotropin (ACTH) test and measurement of plasma ACTH, renin activity, and aldosterone. J Clin Endocrinol Metab. 1992 Jul; 75(1):259-64.

    • Addison's disease in infancy - A Williams, MJ Robinson - Archives of Disease in Childhood, 1956 - adc.bmj.com
    • A case of renal cortical necrosis probably caused by a human equivalent of the Shwartzman reaction - B Lindqvist, P Erlanson, A Brun - Acta medica Scandinavica, 1963 - Wiley Online Library
    • Acute adrenal insufficiency presenting as high output ileostomy - S Rai, D Hemingway - ANNALS-ROYAL COLLEGE OF , 2003 - pubmedcentralcanada.ca
    • Addisonian crisis and relative adrenal failure - WW de Herder, AJ van der Lely - Reviews in endocrine & metabolic , 2003 - Springer
    • [Bilateral ossification of the earlobes. Addisonian crisis in the postoperative period] - RR Rodríguez, LA Ontanilla, RC Rodríguez - Revista espanola de , 1991 - ukpmc.ac.uk
    • Acute adrenal insufficiency during pregnancy and puerperium: case report and literature review - Y Perlitz, J Varkel, J Markovitz, MB Ami - Obstetrical & , 1999 - journals.lww.com
    • Adrenal apoplexy after coronary artery bypass surgery leading to Addisonian crisis. - K Hardy, B Mead, G Gill - Journal of the Royal Society of Medicine, 1992 - ncbi.nlm.nih.gov
    • Mediates permissive effect of glucocorticoids on vascular tone: Perturbations of this mechanism contribute to pathogenesis of Cushing's syndrome and Addison's - L Axelrod - The Lancet, 1983 - Elsevier
    • A case of primary Addison's disease with hyperemesis gravidarum and successful pregnancy - I Ozdemir, F Demirci, O Yücel, E Simsek - European Journal of , 2004 - Elsevier
    • Ambulatory treatment with intravenous norepinephrine in a patient with end stage renal disease and generalized AA amyloidosis - E Wrenger, C Röcken, JÖR Dietzmann - Amyloid, 2002 - informahealthcare.com
    • ADDISONIAN CRISIS: Overexertion brought this patient's adrenal insufficiency to light - M O'Donnell - AJN The American Journal of Nursing, 1997 - journals.lww.com
    • Adrenal insufficiency in the cancer patient: implications for the surgeon - JK Ihde, ADM Turnbull - British journal of surgery, 1990 - Wiley Online Library
    • 21101c hr&oi w is much more coan than th3 - T GLAND - DD 000M, 1473% tPLACWs o UNCLASSIFIM - DTIC Document
    • Addison's disease: familial incidence and occurrence in association with pernicious anemia - R BERLIN - Acta medica Scandinavica, 2009 - Wiley Online Library
    • Addisonian pigmentation due to extreme pyloric stenosis by a mucosal diaphragm - HB Young - British Journal of Surgery, 2005 - Wiley Online Library
    • Mediates permissive effect of glucocorticoids on vascular tone: Perturbations of this mechanism contribute to pathogenesis of Cushing's syndrome and Addison's - L Axelrod - The Lancet, 1983 - Elsevier
    • Acute adrenal insufficiency mimicking septic shock: a case report - MJ Melby, K Bergman, T Ramos - : The Journal of , 1988 - Wiley Online Library
    • Acute reversible cardiomyopathy with cardiogenic shock in a patient with Addisonian crisis: A case report - B Wolff, K Machill, I Schulzki, D Schumacher - International journal of , 2007 - Elsevier
    • Acute monoblastic leukemia with abnormal granules and disseminated intravascular coagulation: Diagnostic pitfalls - R Pohlmann, P Bhargava - American journal of hematology, 2009 - Wiley Online Library
    • Adrenal dysfunction in patients with renal amyloid - P Danby, KPG Harris, B Williams, J Feehally, J Walls - QJM, 1990 - Oxford Univ Press
    • Addisonian crisis as the presenting feature of bilateral primary adrenal lymphoma - S Serrano, L Tejedor, B Garcia, H Hallal, JA Polo - Cancer, 2006 - Wiley Online Library
    • A strategy for management of intraoperative Addisonian crisis during coronary artery bypass grafting - C D'Silva, D Watson, D Ngaage - and Thoracic Surgery, 2012 - icvts.oxfordjournals.org
    • Acute adrenal insufficiency during pregnancy and puerperium: case report and literature review - Y Perlitz, J Varkel, J Markovitz, MB Ami - Obstetrical & , 1999 - journals.lww.com

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