A 46 year old female with a history of rheumatoid arthritis, on daily steroids, presents complaining of abdominal pain, nausea, and vomiting x 5 days. She has been unable to tolerate PO, including her medications for the past three days. Upon arrival, she is afebrile, with a BP of 69/40, and HR 130. Fingerstick glucose is 80. Her BP rises minimally after two liters of NS.
In the setting of her inability to take her medications, what are you concerned about?
What electrolyte abnormalities would you expect to see?
How would you treat this patient further?
The initial signs and symptoms of adrenal insufficiency are often non-specific and commonly include generalized weakness, fatigue, gastrointestinal symptoms and fever.
Most adrenal crises occur in patients with chronic adrenal insufficiency who have an illness or stress that results in inadequate cortisol production; hypotension out of proportion to the severity of that underlying illness and hypotension refractory to standard resuscitation are important clinical clues to adrenal crisis.
Appropriate management of adrenal insufficiency includes treating the precipitating illness, aggressive fluid and pressor resuscitation, and correction of inadequate cortisol by administration of hydrocortisone or dexamethasone.
The adrenal gland is composed of the cortex (which produces aldosterone, androgens, and cortisol) and the medulla (which produces catecholamines) and is in a feedback loop with the hypothalamic-pituitary axis. Adrenal insufficiency can be both primary (Addison’s disease) or secondary (due to lack of ACTH production from the pituitary gland).
In primary adrenal insufficiency, aldosterone production and release are affected, but in secondary adrenal insufficiency, they are not. Aldosterone promotes sodium reabsorption and potassium excretion. Lack of aldosterone in primary adrenal insufficiency contributes to both hyponatremia and hyperkalemia and a potentially greater degree of hypotension. Hyperkalemia is common in primary adrenal insufficiency and is not expected in secondary adrenal insufficiency.
Worldwide, TB is the most common cause of primary adrenal insufficiency. Most cases of primary adrenal insufficiency in the Western world are autoimmune related. Other etiologies of primary adrenal insufficiency include congenital conditions, hemorrhage (due to trauma, anticoagulation, infections [Waterhouse-Friderichsen in meningococcemia]), infiltrative conditions (amyloidosis, hemochromatosis, sarcoidosis), and metastatic cancer. Causes of secondary adrenal insufficiency include pituitary problems (postpartum pituitary necrosis) and, the most common, chronic glucocorticoid use.
[Pearl inspired by Ben Schnapp’s morning report case, answer information provided by PEER VIII]