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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.


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.

Fever
  • Hypotension, lethargy, and fever can all be presenting signs. Secondary addisonian crisis can also result from pituitary apoplexy.[ncbi.nlm.nih.gov]
  • Precipitating causes were mainly gastrointestinal infection and fever (45%) but also other stressful events (e.g. major pain, surgery, psychic distress, heat and pregnancy).[ncbi.nlm.nih.gov]
  • […] 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]
  • Adrenal crisis is characterized by fever, vomiting, diarrhea, and a precipitous fall in blood pressure.[britannica.com]
  • Characteristic symptoms are: Sudden penetrating pain in the legs, lower back or abdomen Confusion, psychosis, slurred speech Severe lethargy Convulsions Fever Hyperkalemia (elevated potassium level in the blood) Hypercalcemia (elevated calcium level in[en.wikipedia.org]
Hypothermia
  • On presentation, the patient will have mild hypothermia, hypoglycemia, and hypotension. The team will have to initiate fluid resuscitation and an initial workup.[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]
Pallor
  • Other signs and symptoms that should draw attention to a previous primary AI are salt craving and vitiligo. 4 , 5 , 20 The clinical picture that allows us to suspect a secondary AI is: pallor, but with no changes in red blood cells that could suggest[scielo.br]
Hodgkin's Disease
  • We describe the case of a 61-year-old male with Hodgkin's disease and metastases in both adrenal glands who was diagnosed with adrenal insufficiency as a result of an acute addisonian crisis.[ncbi.nlm.nih.gov]
Aspiration
  • Fine-needle aspiration biopsy of the adrenal glands revealed a non-Hodgkin lymphoma of predominantly small cleaved cells and a low degree of malignancy.[ncbi.nlm.nih.gov]
Vomiting
  • If unable to retain medication due to vomiting, notify the health care provider.[endocrinesurgery.ucla.edu]
  • Abstract Addisonian crisis represents a state of acute adrenocortical insufficiency and occurs in patient with Addison's disease who are exposed to stress of infection, surgery, trauma, vomiting and diarrhea.[ncbi.nlm.nih.gov]
  • He had a 9-month history of weight loss and vomiting that had led to a previous diagnosis of atypical anorexia, and he had been transferred from a psychiatric clinic.[ncbi.nlm.nih.gov]
  • (Most commonly vomiting and/or diarrhoea due to a gastrointestinal upset.) Injury. Surgery. Burns. Pregnancy. General anaesthesia. Myocardial infarction. Acute allergic reactions. Acute hypoglycaemia in people with diabetes.[patient.info]
Nausea
  • Patients may experience lightheadedness or dizziness, weakness, sweating, abdominal pain, nausea and vomiting, or even loss of consciousness.[endocrinesurgery.ucla.edu]
  • All presented with a history of long-standing lethargy, nausea, weight loss, dyspnea, chest pain, and striking hyperpigmentation.[ncbi.nlm.nih.gov]
  • Nausea, vomiting, headache, and fatigue are also common symptoms alongside profound sweating that is localized on the palmar surface of the hands and face.[symptoma.com]
  • […] 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 - confusion - nausea[signsandsyndromes.com]
Abdominal Pain
  • Patients may experience lightheadedness or dizziness, weakness, sweating, abdominal pain, nausea and vomiting, or even loss of consciousness.[endocrinesurgery.ucla.edu]
  • It is equally important in all persons with chronic abdominal pain for whom surgery is considered necessary FULL TEXT[annals.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.[endocrinesurgery.ucla.edu]
  • 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]
  • 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]
  • The syndrome usually starts with nausea, vomiting, loss of appetite, and diarrhea with unspecific abdominal cramps. Such gastrointestinal manifestations of an acute Addisonian crisis can be accompanied by fever, chills, and profuse sweating.[news-medical.net]
Coffee Ground Emesis
  • He returned to hospital the same night with coffee-ground emesis and in Addisonian crisis requiring parenteral steroids and intensive care unit support.[ncbi.nlm.nih.gov]
Hypotension
  • A case is reported of constrictive pericarditis in which the patient developed protracted hypotension which was unresponsive to inotropic therapy, following pericardiectomy.[ncbi.nlm.nih.gov]
  • Abstract In a patient who developed clinical signs of intracranial hypertension, bilateral papilledema and diplopia, in association with mild hypotension, hyponatremia and hyperkalemia, the hypothesis of Addison's disease was raised and confirmed.[ncbi.nlm.nih.gov]
  • Abstract Three women were admitted to the surgical wards with acute gastro-intestinal symptoms and despite good clinical (pigmentation, hypotension) and biochemical (hyponatraemia, acidosis) evidence of Addisonian crisis had unnecessary investigations[ncbi.nlm.nih.gov]
  • When faced with such a patient who has hypotension and ischemic ECG changes without having underlying angina, Addisonian crisis should be considered in differential diagnosis.[ncbi.nlm.nih.gov]
  • Immediately after starting the procedure, the patient developed profound hypotension unresponsive to intravenous fluids and vasopressors, consistent with Addisonian crisis.[ncbi.nlm.nih.gov]
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]
  • Therefore, it is essential that all health professionals are able to recognize the nonspecific symptoms that include orthostatic hypotension unresponsive to volume, anorexia, muscle weakness, paleness, nausea, and vomiting, and at least suspect a possible[scielo.br]
Scrotal Mass
  • METHODS: A case of acute primary adrenal insufficiency associated with bilaterally enlarged adrenal glands is reported, along with the subsequent finding of a scrotal mass diagnosed as tuberculous epididymo-orchitis.[ncbi.nlm.nih.gov]
Papilledema
  • Abstract In a patient who developed clinical signs of intracranial hypertension, bilateral papilledema and diplopia, in association with mild hypotension, hyponatremia and hyperkalemia, the hypothesis of Addison's disease was raised and confirmed.[ncbi.nlm.nih.gov]

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.

Hyponatremia
  • Abstract In a patient who developed clinical signs of intracranial hypertension, bilateral papilledema and diplopia, in association with mild hypotension, hyponatremia and hyperkalemia, the hypothesis of Addison's disease was raised and confirmed.[ncbi.nlm.nih.gov]
  • BACKGROUND: A 22-year-old man was admitted to an intensive care unit with severe hyponatremia, hypotension and somnolence.[ncbi.nlm.nih.gov]
  • […] 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]
  • Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia. The team will need to treat the hyperkalemia and initiate hydrocortisone therapy.[emsimcases.com]
  • Hypoglycemia (reduced level of blood glucose) Hyponatremia (low sodium level in the blood) Hypotension (low blood pressure) Hypothyroid (low T4 level) Severe vomiting and diarrhea, resulting in dehydration Syncope (loss of consciousness and ability to[en.wikipedia.org]
ST Elevation
  • Additionally, profound ECG abnormalities with diffuse ST-elevation and decreased QRS-amplitudes occurred, whereas Troponin-I was only moderately increased. Chest X-ray displayed bilateral pulmonary edema.[ncbi.nlm.nih.gov]
Liver Biopsy
  • Abstract A 56-year-old man with persistently elevated liver enzyme levels, fatigue, lethargy and a 9.0 kg weight loss over six months underwent a percutaneous liver biopsy that demonstrated multiple granulomas.[ncbi.nlm.nih.gov]

Treatment

  • People on treatment for adrenal insufficiency do not require cover for minor dental procedures such as fillings.[patient.info]
  • Treatment: In adrenal crisis, an intravenous or intramuscular injection of hydrocortisone (an injectable corticosteroid) must be given immediately. Supportive treatment of low blood pressure with intravenous fluids is usually necessary.[endocrinesurgery.ucla.edu]
  • Screening serologies were positive for histoplasmosis, and he was started on itraconazole treatment.[ncbi.nlm.nih.gov]
  • 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. Shock may occur if treatment is not provided early, and it can be life threatening.[nlm.nih.gov]
  • The possibility that many patients with tuberculosis have adrenal involvement with limited hormonal reserve and that they may develop incipient adrenal failure on commencing treatment is discussed.[ncbi.nlm.nih.gov]

Prognosis

  • Expectations (prognosis): Death may occur due to overwhelming shock if early treatment is not provided.[endocrinesurgery.ucla.edu]
  • Incidence Predisposing Factors Macroscopic Features Clinical History Clinical Examination General Investigation Specific Investigations Prognosis Treatment Overview References Drugs/Products Associated with Addison’s Disease Incidence About 1 in 100,000[myvmc.com]
  • […] adrenalitis): enlargement of both adrenal glands, with necrotic centers and peripheral enhancing rims chronic : both adrenal glands appear small and atrophic, associated with calcifications ( adrenal calcification ) in granulomatous adrenalitis Treatment and prognosis[radiopaedia.org]
  • Prognosis Adrenal crisis is not a common event, but when it does occur it can carry a high mortality.[ncbi.nlm.nih.gov]

Etiology

  • OBJECTIVE: To describe a case of acute primary adrenal insufficiency in which tuberculosis was subsequently detected as the etiologic factor when the patient presented with tuberculous epididymo-orchitis.[ncbi.nlm.nih.gov]
  • An extensive history should be obtained to determine the etiology of these findings.[ncbi.nlm.nih.gov]
  • In patients with shock of unknown etiology, the clinician must include adrenal insufficiency in the differential and should have a low threshold to give stress dose steroids.[imedpub.com]
  • Classified as primary or secondary in etiology, but both types can lead to adrenal crisis.[coreem.net]
  • Etiology An Addisonian crisis results from an acute lack of glucocorticoids or mineralocorticoids. This condition most often occurs in a patient with known adrenal insufficiency, either primary or secondary.[ncbi.nlm.nih.gov]

Epidemiology

  • Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol . 2010 Mar. 162(3):597-602. [Medline] . Smans LC, Van der Valk ES, Hermus AR, Zelissen PM.[emedicine.medscape.com]
  • Epidemiology An Addisonian crisis frequently occurs in patients with known adrenal insufficiency.[ncbi.nlm.nih.gov]
  • Furthermore, research on the epidemiology of this complication reveal a consistent picture with an incidence range between five and ten adrenal crises per 100 patient/years in individuals on standard replacement therapy.[news-medical.net]
  • Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies . Eur. J. Endocrinol. 162 , 597–602 (2010). Download references Acknowledgements Written consent for publication was obtained from the patient.[nature.com]
  • Epidemiology of primary and secondary adrenal insufficiency: Prevalence and incidence, acute adrenal insufficiency, long-term morbidity and mortality. Ann. Endocrinol. (Paris). 2017 Dec; 78 (6):490-494. [ PubMed : 29174931 ] 8.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Signs and Symptoms Investigations Treatment Further References and Resources[aci.health.nsw.gov.au]
  • […] cyproterone, rifampin, dilantin congenital adrenal hyperplasia, adrenoleukodystrophy, familiy glucocorticoid deficiency Secondary, ACTH deficiency, can be caused by: chronic glucocorticoid therapy hypopituitarism (ie pituitary tumour) return to top Pathophysiology[sharinginhealth.ca]
  • Pathophysiologically, there is significant hyponatremia and hyperkalemia, often associated with metabolic acidosis, hypoglycemia, and (every so often) hypercalcemia.[news-medical.net]
  • Pathophysiology: The adrenal cortex produces 3 steroid hormones: glucocorticoids (cortisol), mineralocorticoids (aldosterone, 11-deoxycorticosterone), and androgens (dehydroepiandrosterone).[addisons-help.com]
  • For better anatomical and pathophysiological understanding of the subject, important books in the academic circles were also used as a source of knowledge.[scielo.br]

Prevention

  • Only a limited number of risk factors suitable for targeting prevention of AC were identified. These findings indicate the need for new concepts of crisis prevention in patients with AI.[ncbi.nlm.nih.gov]
  • Preventing an Addisonian Crisis While it is not always possible to prevent an addisonian crisis, there are some things that a person can do in order to reduce the chances of requiring addisonian crisis treatment: A person with Addison's disease should[endocrine-system.emedtv.com]
  • Preventing Addisonian Crisis Currently, there are no known methods to prevent Addison’s disease. However, steps can be taken to prevent Addisonian crisis in people already diagnosed with the disease.[innerbody.com]
  • To prevent an adrenal crisis, it is crucial that patients be educated on the need to increase their dose with illness.[csrf.net]
  • Medical Emergency - Addisonian crisis is an emergency that needs sorting to prevent death from shock! What is it? An acute episode of adrenal insufficiency. That means the adrenal glands stop producing cortisol .[medrevise.co.uk]

References

Article

  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.

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Last updated: 2018-06-22 06:58