Acute adrenal insufficiency adrenal crisis

Acute adrenal insufficiency is a true endocrinological emergency. It usually presents as shock in a previously undiagnosed patient with (primary) hypoadrenalism who has been subjected to major stress or in a patient with established hypoadrenalism who does not or is not able to increase glucocorticoid replacement during an intercurrent illness or injury. A febrile illness, bacterial infection, trauma, surgery, dehydration, or any other intercurrent illness in these patients can trigger acute adrenal failure as the diseased adrenal cortex is unable to respond adequately to this type of stress. Acute hypoadrenalism can also result from bilateral adrenal hemorrhage, embolus or thrombosis, and, rarely, adrenal vein thrombosis (Rao.. §t,§L 1.989; Olth §L§L 1992). In the intensive care setting bilateral hemorrhage is most commonly seen in overwhelming sepsis, classically in meningococcemia but also in other Gram-negative sepsis (e.g. Pseudomonas aeruginosa), use of anticoagulants, and HIV infection.

Symptoms are generally non-specific and may include vomiting, diarrhea, abdominal pain, weakness, myalgias, joint pains, lethargy, confusion, delirium, or even coma. Most patients have fever due to the precipitating infection, but also without infection and often out of proportion to any minor infection. Fever and abdominal pain and tenderness can mimic an acute surgical abdomen. Acute flank, lower chest, or back pain can be present in patients with acute adrenal hemorrhagic necrosis in addition to other signs and symptoms of adrenal crisis (Raoetal: 1989). Abdominal rigidity or rebound may be observed (RaoeLaL 1989). Shock in adrenal crisis usually presents as hypovolemic shock due to a marked loss of plasma volume, but after correction of hypovolemia a hyperdynamic profile is often present, mimicking septic shock (Bouachour.. eL§L 1994). Shock due to adrenal crisis may be masked by or contribute to circulatory shock associated with other concomitant critical illness, particularly septic shock.

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