History

Fact Explanation
A known patient with adrenal insufficiency. Adrenal insufficiency is a rare but life-threatening condition where adrenal cortex is dysfunctional either primarily (mostly due to autoimmune conditions) or secondarily (mostly due to hypothalamo-pituitary axis suppression). [1] [2] [3] [4] The patients might present with their previous diagnosis. [5]
Sudden syncope Normal cardiovascular reactivity which is maintained by catecholamines, requires glucocorticoids for maintenance of vascular tone and cardiac contractility. [6] In adrenal insufficiency, especially in acute setting, the rapid loss of vasomotor response causes cardiovascular collapse and fainting. [7] There can be associated cardiogenic shock also. [6] Shock can preogress to coma and death if left untreated. [5] The proposed pathophysiological mechanisma are hypovolemic shock due to decreased preload, depressed myocardial contractility, and increased systemic vascular resistance.
Sudden weakness and fatigue, especially when standing up. Due to postural hypotension caused by loss of vasomotor tone. [6] [8] [9]
Acute abdominal pain. Abdominal pain has been reported quite often in acute adrenal insufficiency. [10] [11] [12] The pain itself could have been the trigger factor in decompensating well-controlled disease. [15]
Fever Hormonal hyperthermia has been reported in adrenal insufficiency. [14] [15] [16] [17]
A history of stressful condition There have been various precipitating factors associated with adrenal crisis identified. [18] Especially the critically ill have been associated with very low corticosteroid levels and high mortality rates. [19] Normally in critical illness, adrenal responsiveness to exogenous corticotropin is normally maintained. And during such critical periods the steroid binding globulins are reduced, in turn free corticosteroids are increased. They are important mechanisms in recovery. [19] Even though it is so, during severe illnesses, the hypothalo-pituitary axis can be suppressed and there can be acute reduction of glucocorticosteroids, or an insidious loss during the course of illness. [19] [20] The known predisposing factors are surgeries, trauma, infections, sepsis, and hemorrhage. [21] [22] [23] [24] [25] [26] [27] [28] The well-known infections to precipitate a crisis an hypoadrenalism are dental infections, mycobacterium infections (tuberculosis), Human Immunodeficiency VIrus (HIV) and fungi. [29] [30] [31] [32] [33] [34] [35] [36] [37]
A history of non-adherence to treatments Abrupt withdrawal of steroids causes adrenal crisis in patients who have been on long-term steroid therapy because the exogenous glucocorticoids suppress the adrenal axis and acutely there is a steroid deficiency. The risk of developing adrenal insufficiency after steroid withdrawal is dose-dependent. [38] [39] [40] [41] [42] [43]
References
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  2. NEARY NICOLA, NIEMAN LYNNETTE. Adrenal insufficiency: etiology, diagnosis and treatment. Current Opinion in Endocrinology, Diabetes and Obesity [online] 2010 June, 17(3):217-223 [viewed 20 May 2014] Available from: doi:10.1097/MED.0b013e328338f608
  3. HAHNER STEFANIE, ALLOLIO BRUNO. Management of adrenal insufficiency in different clinical settings. Expert Opin. Pharmacother. [online] 2005 November, 6(14):2407-2417 [viewed 20 May 2014] Available from: doi:10.1517/14656566.6.14.2407
  4. WATTS NELSON B.. Rapid Assessment of Corticotropin Reserve After Pituitary Surgery. JAMA [online] 1988 February [viewed 20 May 2014] Available from: doi:10.1001/jama.1988.03720050044021
  5. OMORI KAZUE, NOMURA KAORU, SHIMIZU SATORU, OMORI NARIKO, TAKANO KAZUE. Risk Factors for Adrenal Crisis in Patients with Adrenal Insufficiency. Endocr J [online] 2003 December, 50(6):745-752 [viewed 21 May 2014] Available from: doi:10.1507/endocrj.50.745
  6. MEKONTSO-DESSAP A. Images in Cardiology: Acute adrenal insufficiency complicated by cardiogenic shock. Heart [online] 2005 April, 91(4):e31-e31 [viewed 20 May 2014] Available from: doi:10.1136/hrt.2004.055095
  7. PALLAIS J. CARL, SCHLOZMAN STEVEN C., PUIG ALBERTO, PURCELL JOHN J., STERN THEODORE A.. Fainting, Swooning, and Syncope. Prim. Care Companion CNS Disord. [online] 2011 July [viewed 20 May 2014] Available from: doi:10.4088/PCC.11f01187
  8. SCOTT LUCINDA V., MEDBAK SAMI, DINAN TIMOTHY G.. The low dose ACTH test in chronic fatigue syndrome and in health. Clin Endocrinol [online] 1998 June, 48(6):733-737 [viewed 20 May 2014] Available from: doi:10.1046/j.1365-2265.1998.00418.x
  9. NIEMAN LYNNETTE K., CHANCO TURNER MARIA L.. Addison's disease. Clinics in Dermatology [online] 2006 July, 24(4):276-280 [viewed 20 May 2014] Available from: doi:10.1016/j.clindermatol.2006.04.006
  10. ELASHA H. M. S., ANJUM F., ALMALKI M. H.. A young man with a dizzy spell and acute abdominal pain. Clinical Medicine [online] December, 13(5):520-521 [viewed 20 May 2014] Available from: doi:10.7861/clinmedicine.13-5-520
  11. SIMM PJ, MCDONNELL CM, ZACHARIN MR. Primary adrenal insufficiency in childhood and adolescence: Advances in diagnosis and management. J Paediatr Child Health [online] 2004 November, 40(11):596-599 [viewed 20 May 2014] Available from: doi:10.1111/j.1440-1754.2004.00482.x
  12. SOULE STEVEN. Addison's disease in Africa-a teaching hospital experience. Clin Endocrinol [online] 1999 January, 50(1):115-120 [viewed 20 May 2014] Available from: doi:10.1046/j.1365-2265.1999.00625.x
  13. KHALAF M. W., KHADER R., COBETTO G., YEPES J. F., KAROUNOS D. G., MILLER C. S.. Risk of adrenal crisis in dental patients: Results of a systematic search of the literature. Journal of the American Dental Association [online] December, 144(2):152-160 [viewed 20 May 2014] Available from: doi:10.14219/jada.archive.2013.0094
  14. EMEKSIZ HAMDI, BAKKALOGLU SEVCAN, CAMURDAN ORHUN, BOYRAZ MEHMET, SOYLEMEZOGLU OGUZ, HASANOGLU ENVER, BUYAN NECLA. Acute adrenal crisis mimicking familial Mediterranean fever attack in a renal transplant FMF patient with amyloid goiter. Rheumatol Int [online] December, 30(12):1647-1649 [viewed 21 May 2014] Available from: doi:10.1007/s00296-009-1115-0
  15. NAKA NORIFUMI, TAKENAKA SATOSHI, NANNO KATSUHIKO, MORIGUCHI YU, CHUN BANG-MI, SONODA SHUNJI, HASHIMOTO NOBUYUKI, TSUKAMOTO YOSHITANE, ARAKI NOBUHITO. Acute adrenal crisis after orthopedic surgery for pathologic fracture. World J Surg Onc [online] 2007 December [viewed 21 May 2014] Available from: doi:10.1186/1477-7819-5-27
  16. KUBO SHIN-ICHI, ISHIGAMI AKIKO, GOTOHDA TAKAKO, TOKUNAGA ITSUO, KITAMURA OSAMU. An autopsy case of adrenal insufficiency 20 years after Hypophysectomy: Relation between stress and cause of death. J. Med. Invest. [online] 2006 December, 53(1,2):183-187 [viewed 21 May 2014] Available from: doi:10.2152/jmi.53.183
  17. LEE, SANG-OH, EGI M. and KOH Y. Fever in the Intensive Care Unit Patient. [web] Available at http://www.antimicrobe.org/e60.asp
  18. BORNSTEIN STEFAN R.. Predisposing Factors for Adrenal Insufficiency. N Engl J Med [online] 2009 May, 360(22):2328-2339 [viewed 21 May 2014] Available from: doi:10.1056/NEJMra0804635
  19. LIGTENBERG JACK J. M., TULLEKEN JAAP E., VAN DER WERF TJIP S., ZIJLSTRA JAN G.. Unraveling the Mystery of Adrenal Failure in the Critically Ill. Critical Care Medicine [online] 2004 June, 32(6):1447-1448 [viewed 21 May 2014] Available from: doi:10.1097/01.CCM.0000129098.81978.45
  20. HETZ W, KAMP HD, ZIMMERMANN U, VON BOHLEN A, WILDT L, SCHUETTLER J. Stress hormones in accident patients studied before admission to hospital. J Accid Emerg Med [online] 1996 Jul, 13(4):243-247 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1342721
  21. CHERNOW BART. Hormonal Responses to Graded Surgical Stress. Arch Intern Med [online] 1987 July [viewed 21 May 2014] Available from: doi:10.1001/archinte.1987.00370070087013
  22. SARKAR SOUMYABRATA, SARKAR SUBRATA, GHOSH SUPRATIM, BANDYOPADHYAY SUBHANKAR. Addison′s disease. Contemp Clin Dent [online] 2012 December [viewed 21 May 2014] Available from: doi:10.4103/0976-237X.107450
  23. CATALANO RICHARD D.. Mechanisms of Adrenocortical Depression During Escherichia coli Shock. Arch Surg [online] 1984 February [viewed 21 May 2014] Available from: doi:10.1001/archsurg.1984.01390140011002
  24. RIVERS EMANUEL P., BLAKE HEIDI C., DERECZYK BARRY, RESSLER JULIE A., TALOS ELLEN L., PATEL RAKESH, SMITHLINE HOWARD A., RADY MOHAMED Y., WORTSMAN JACOBO. Adrenal Dysfunction in Hemodynamically Unstable Patients in the Emergency Department. Acad Emergency Med [online] 1999 June, 6(6):626-630 [viewed 21 May 2014] Available from: doi:10.1111/j.1553-2712.1999.tb00417.x
  25. ASARE KWAME. Diagnosis and Treatment of Adrenal Insufficiency in the Critically Ill Patient. Pharmacotherapy [online] 2007 November, 27(11):1512-1528 [viewed 21 May 2014] Available from: doi:10.1592/phco.27.11.1512
  26. LIGTENBERG JACK J. M., TULLEKEN JAAP E., VAN DER WERF TJIP S., ZIJLSTRA JAN G.. Unraveling the Mystery of Adrenal Failure in the Critically Ill. Critical Care Medicine [online] 2004 June, 32(6):1447-1448 [viewed 21 May 2014] Available from: doi:10.1097/01.CCM.0000129098.81978.45
  27. WEANT KYLE A., SASAKI-ADAMS DEANNA, DZIEDZIC KATHRYN, EWEND MATTHEW. Acute Relative Adrenal Insufficiency After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery [online] 2008 October, 63(4):645-650 [viewed 21 May 2014] Available from: doi:10.1227/01.NEU.0000325728.50939.15
  28. WANG PING. Mechanism of Adrenal Insufficiency Following Trauma and Severe Hemorrhage. Arch Surg [online] 1999 April [viewed 21 May 2014] Available from: doi:10.1001/archsurg.134.4.394
  29. MILENKOVIC ANA, MARKOVIC DEJAN, ZDRAVKOVIC DRAGAN, PERIC TAMARA, MILENKOVIC TATJANA, VUKOVIC RADE. Adrenal crisis provoked by dental infection: case report and review of the literature. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology [online] 2010 September, 110(3):325-329 [viewed 23 May 2014] Available from: doi:10.1016/j.tripleo.2010.04.025
  30. ANNANE DJILLALI. Adrenal insufficiency in sepsis. Current Pharmaceutical Design [online] 2008 July, 14(19):1882-1886 [viewed 23 May 2014] Available from: doi:10.2174/138161208784980626
  31. SANTIAGO ANGELA H., RATZAN SUSAN. Acute Adrenal Crisis in an Asthmatic Child Treated with Inhaled Fluticasone Proprionate. International Journal of Pediatric Endocrinology [online] 2010 December, 2010:1-4 [viewed 23 May 2014] Available from: doi:10.1155/2010/749239
  32. TOBON A. M., AGUDELO C. A., RESTREPO C. A., VILLA C. A., QUICENO W., ESTRADA S., RESTREPO A.. Adrenal Function Status in Patients with Paracoccidioidomycosis after Prolonged Post-Therapy Follow-Up. American Journal of Tropical Medicine and Hygiene [online] December, 83(1):111-114 [viewed 23 May 2014] Available from: doi:10.4269/ajtmh.2010.09-0634
  33. SHAH ZAFARAMIN, WANI FAYAZAHMAD, WAHID ABDUL, PARVEEN SHAHEENA, NAZIR ARJUMAND, MAQBOOL MUZAFFAR. Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock. Indian J Crit Care Med [online] 2009 December [viewed 23 May 2014] Available from: doi:10.4103/0972-5229.56054
  34. AGUDELO CARLOS ANDRéS, MUñOZ CAROLINA, RAMíREZ ALEX, GUTIERREZ JONHAIRO, VELEZ SANTIAGO, PEREZ JUAN CAMILO, VELEZ ALEJANDRO, TOBON ANGELA MARíA, RESTREPO ANGELA. Identification of Paracoccidioides brasiliensis in adrenal glands biopsies of two patients with paracoccidioidomycosis and adrenal insufficiency. Rev. Inst. Med. trop. S. Paulo [online] 2009 February [viewed 23 May 2014] Available from: doi:10.1590/S0036-46652009000100008
  35. HADDARA W. M.R.. TB and adrenal insufficiency. Canadian Medical Association Journal [online] 2004 September, 171(7):710-710 [viewed 23 May 2014] Available from: doi:10.1503/cmaj.1041046
  36. AL-MAMARI A, BALKHAIR A, GUJJAR A, BEN ABID F, AL-FARQANI A, AL-HAMADANI A, JAIN R. A Case of Disseminated Tuberculosis with Adrenal Insufficiency Sultan Qaboos Univ Med J [online] 2009 Dec, 9(3):324-327 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074785
  37. SINHA UMA, MUKHOPADHYAY PRASANTA, SENGUPTA NILANJAN, ROY KESHABSINHA. Human immunodeficiency virus endocrinopathy. Indian J Endocr Metab [online] 2011 December [viewed 23 May 2014] Available from: doi:10.4103/2230-8210.85574
  38. HUBER BENEDIKT M, BOLT ISABEL B, SAUVAIN MARIE-JOSèPHE, FLüCK CHRISTA E. Adrenal insufficiency after glucocorticoid withdrawal in children with rheumatic diseases. [online] December, 99(12):1889-1893 [viewed 21 May 2014] Available from: doi:10.1111/j.1651-2227.2010.01936.x
  39. EINAUDI SILVIA, BERTORELLO NICOLETTA, MASERA NICOLETTA, FARINASSO LOREDANA, BARISONE ELENA, RIZZARI CARMELO, CORRIAS ANDREA, VILLA ALESSIA, RIVA FRANCESCA, SARACCO PAOLA, PASTORE GUIDO. Adrenal axis function after high-dose steroid therapy for childhood acute lymphoblastic leukemia. Pediatr. Blood Cancer [online] December, 50(3):537-541 [viewed 21 May 2014] Available from: doi:10.1002/pbc.21339
  40. MORTIMER K J. Oral and inhaled corticosteroids and adrenal insufficiency: a case-control study. Thorax [online] 2006 May, 61(5):405-408 [viewed 21 May 2014] Available from: doi:10.1136/thx.2005.052456
  41. SHULMAN D. I., PALMERT M. R., KEMP S. F.. Adrenal Insufficiency: Still a Cause of Morbidity and Death in Childhood. PEDIATRICS [online] December, 119(2):e484-e494 [viewed 21 May 2014] Available from: doi:10.1542/peds.2006-1612
  42. BHATTACHARYYA A, KAUSHAL K, TYMMS D J, DAVIS J R E. Steroid withdrawal syndrome after successful treatment of Cushing's syndrome: a reminder. European Journal of Endocrinology [online] December, 153(2):207-210 [viewed 21 May 2014] Available from: doi:10.1530/eje.1.01953
  43. HOPKINS RACHEL L., LEINUNG MATTHEW C.. Exogenous Cushing's Syndrome and Glucocorticoid Withdrawal. Endocrinology and Metabolism Clinics of North America [online] 2005 June, 34(2):371-384 [viewed 21 May 2014] Available from: doi:10.1016/j.ecl.2005.01.013

Examination

Fact Explanation
Characteristic hyperpigmentation of the skin The charcteristic pigmentation pattern in Addisonsdisease is generalized hyperpigmentation which is classically described as “bronzing”. It is more prominent on sun-exposed areas and over pressure points, such as the elbows and knees, vermilion border, recent scars, genital skin, and oral mucosa. These are caused by increased levels of beta-lipotropin or Adrenocorticotropic hormone, each of which can stimulate melanocyte production. Intra-oral pigmentations occur earlier than skin, and it happens over a time period of months to years. In some autoimmune adrenalitis syndromes patients may have vitiligo as a part of the syndrome. [1] [2] [3] [4] [5]
Low blood pressure Due to loss of vasomotor tone, hypovolemia and shock. The hypotension is usually refractory to fluid therapy of vasopressors. [5] [6] [7] [8] [9] [10] [11] Orthostatic hypotension is also an observation. [12] [13]
References
  1. SARKAR SOUMYABRATA, SARKAR SUBRATA, GHOSH SUPRATIM, BANDYOPADHYAY SUBHANKAR. Addison′s disease. Contemp Clin Dent [online] 2012 December [viewed 21 May 2014] Available from: doi:10.4103/0976-237X.107450
  2. NIEMAN LYNNETTE K., CHANCO TURNER MARIA L.. Addison's disease. Clinics in Dermatology [online] 2006 July, 24(4):276-280 [viewed 21 May 2014] Available from: doi:10.1016/j.clindermatol.2006.04.006
  3. MARTíN MARTORELL P, ROEP BO, SMIT JW. Autoimmunity in Addison's disease. Neth J Med [online] 2002 Aug, 60(7):269-75 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12430572
  4. BROSNAN CM, GOWING NF. Addison's disease. BMJ [online] 1996 Apr 27, 312(7038):1085-1087 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350885
  5. GOODWIN TJ, KIND PR, BOGOMOLETZ VW. Addison's disease without pigmentation Postgrad Med J [online] 1973 May, 49(571):305-308 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2495861
  6. SHAHEEN K., ALRAIYES A. H., BAIBARS M., ALRAIES M. C.. Hyperpigmentation and hypotension. Cleveland Clinic Journal of Medicine [online] December, 79(5):308-312 [viewed 21 May 2014] Available from: doi:10.3949/ccjm.79a.10187
  7. BENNET N, GABRIELLI A, CHERNOW B. Hypotension and adrenal insufficiency. Journal of Clinical Anesthesia [online] 1999 August, 11(5):425-430 [viewed 21 May 2014] Available from: doi:10.1016/S0952-8180(99)00072-0
  8. ASARE KWAME. Diagnosis and Treatment of Adrenal Insufficiency in the Critically Ill Patient. Pharmacotherapy [online] 2007 November, 27(11):1512-1528 [viewed 21 May 2014] Available from: doi:10.1592/phco.27.11.1512
  9. RUNER EVELYN R., OSTERMAN JURAJ, BRENNAN J. ROBERT. Adrenal Insufficiency In a Patient With Severe Hypotension Caused By Bilateral Adrenal Hemorrhage. Endocrine Practice [online] December, 8(4):307-310 [viewed 21 May 2014] Available from: doi:10.4158/EP.8.4.307
  10. MEKONTSO-DESSAP A. Images in Cardiology: Acute adrenal insufficiency complicated by cardiogenic shock. Heart [online] 2005 April, 91(4):e31-e31 [viewed 20 May 2014] Available from: doi:10.1136/hrt.2004.055095
  11. PALLAIS J. CARL, SCHLOZMAN STEVEN C., PUIG ALBERTO, PURCELL JOHN J., STERN THEODORE A.. Fainting, Swooning, and Syncope. Prim. Care Companion CNS Disord. [online] 2011 July [viewed 20 May 2014] Available from: doi:10.4088/PCC.11f01187
  12. SCOTT LUCINDA V., MEDBAK SAMI, DINAN TIMOTHY G.. The low dose ACTH test in chronic fatigue syndrome and in health. Clin Endocrinol [online] 1998 June, 48(6):733-737 [viewed 20 May 2014] Available from: doi:10.1046/j.1365-2265.1998.00418.x
  13. NIEMAN LYNNETTE K., CHANCO TURNER MARIA L.. Addison's disease. Clinics in Dermatology [online] 2006 July, 24(4):276-280 [viewed 20 May 2014] Available from: doi:10.1016/j.clindermatol.2006.04.006

Differential Diagnoses

Fact Explanation
Acute hypoglycemia Sudden onset dizziness, fainting and shock can be features of hypoglycemia and adrenal crisis both. Hypoglycemia may be there in fasted Addisons patients, or it may occur as a part of the syndrome spontaneously. [1] [2] [3] [4] [5] Random blood glucose at the admission is mandatory. [6]
Hyperkalemia The patients with high serum potassium levels can present asymptomatic or with cardiac complications. The common features are weakness, fatigue and paresis. Emergency ECG should be taken to assess the cardiac status while waiting for serum electrolyte analysis. [7] [8] [9] [10] Hypoadrenalism can cause hyperkalemia. [11] [12] [13] [14] It can be severe and life-threatening if it's co-existent with diabetes mellitus. [15]
Hypercalcemia Sine the Addisons disease presentation is vague and non-specific until some time when a crisis develops. Hypercalcemia also presents with some of these symptoms as well, with constipation, abmominal pain, tremors and weakness. [16]. Addisons disease also can cause hypercalcemia when there is fluid depletion and resultant low glomerular filtration pressure. [17] [18] [19]
Hyponateremia Patients with hyponatremia usually present with some other co-morbidities rather than the clinical features of hyponatremia itself. It's usually found on investigations. But severe hyponatremia can cause malaise, lethargy, seizures and even coma, permanent brain damage, respiratory arrest, brain-stem herniation, and death. [20] [21] Hypoadrenalism can cause hyponatremia as well. [22] [23] [24]
Septic shock Septic shock and adrenal crisis may be difficult to differentiate. Infection can cause both clinical entities. In patients presenting with fever and features of cardiovascular demise, both conditions should be considered and managed together. [25] [26]
References
  1. MORITA S., OTSUKI M., IZUMI M., ASANUMA N., IZUMOTO S., SAITOH Y., YOSHIMINE T., KASAYAMA S.. Reduced epinephrine reserve in response to insulin-induced hypoglycemia in patients with pituitary adenoma. European Journal of Endocrinology [online] 2007 September, 157(3):265-270 [viewed 21 May 2014] Available from: doi:10.1530/EJE-07-0176
  2. KROMAH FATUMA, TYROCH ALAN, MCLEAN SUSAN, HUGHES HAROLD, FLAVIN NINA, LEE SOYOUNG. Relative Adrenal Insufficiency in the Critical Care Setting: Debunking the Classic Myth. World J Surg [online] December, 35(8):1818-1823 [viewed 21 May 2014] Available from: doi:10.1007/s00268-011-1126-3
  3. DIéGUEZ FELECHOSA MARTA, VALDéS GALLEGO NURIA, GARCíA-ALCALDE FERNáNDEZ MARíA LUISA, CASAL ALVAREZ FLORENTINO. Hypoglycemia as a manifestation of iatrogenic adrenal insufficiency due to topical steroids. Endocrinología y Nutrición [online] 2013 November, 60(9):e21-e22 [viewed 21 May 2014] Available from: doi:10.1016/j.endonu.2013.01.005
  4. DUNLOP K.A., CARSON D.J., SHIELDS M.D.. Hypoglycemia due to adrenal suppression secondary to high-dose nebulized corticosteroid. Pediatr. Pulmonol. [online] December, 34(1):85-86 [viewed 21 May 2014] Available from: doi:10.1002/ppul.10132
  5. DALY LAUREN P, OSTERHOUDT KEVIN C, WEINZIMER STUART A. Presenting features of idiopathic ketotic hypoglycemia. The Journal of Emergency Medicine [online] 2003 July, 25(1):39-43 [viewed 21 May 2014] Available from: doi:10.1016/S0736-4679(03)00100-8
  6. SHUKLA G. J.. Syncope. Circulation [online] 2006 April, 113(16):e715-e717 [viewed 21 May 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.602250
  7. LEHNHARDT ANJA, KEMPER MARKUS J.. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol [online] December, 26(3):377-384 [viewed 21 May 2014] Available from: doi:10.1007/s00467-010-1699-3
  8. PARHAM WA, MEHDIRAD AA, BIERMANN KM, FREDMAN CS. Hyperkalemia Revisited Tex Heart Inst J [online] 2006, 33(1):40-47 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1413606
  9. SOOD MANISH M., SOOD AMY R., RICHARDSON ROBERT. Emergency Management and Commonly Encountered Outpatient Scenarios in Patients With Hyperkalemia. Mayo Clinic Proceedings [online] 2007 December, 82(12):1553-1561 [viewed 21 May 2014] Available from: doi:10.1016/S0025-6196(11)61102-6
  10. ALFONZO ANNETTE V.M., ISLES CHRIS, GEDDES COLIN, DEIGHAN CHRIS. Potassium disorders—clinical spectrum and emergency management. Resuscitation [online] 2006 July, 70(1):10-25 [viewed 21 May 2014] Available from: doi:10.1016/j.resuscitation.2005.11.002
  11. OELKERS W., BAHR V.. Effects of fludrocortisone withdrawal on plasma angiotensin II, ACTH, vasopressin, and potassium in patients with Addison's disease. European Journal of Endocrinology [online] 1987 July, 115(3):325-330 [viewed 22 May 2014] Available from: doi:10.1530/acta.0.1150325
  12. VAN BUREN M, BOER P, KOOMANS H A. Effects of acute mineralocorticoid and glucocorticoid receptor blockade on the excretion of an acute potassium load in healthy humans.. The Journal of Clinical Endocrinology & Metabolism [online] 1993 October, 77(4):902-909 [viewed 22 May 2014] Available from: doi:10.1210/jcem.77.4.8408463
  13. HORISBERGER JD, DIEZI J. Effects of mineralocorticoids on Na+ and K+ excretion in the adrenalectomized rat. Am J Physiol [online] 1983 Jul, 245(1):F89-99 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6869541
  14. MORRIS DAVID J.. The Metabolism and Mechanism of Action of Aldosterone*. Endocrine Reviews [online] 1981 January, 2(2):234-247 [viewed 22 May 2014] Available from: doi:10.1210/edrv-2-2-234
  15. HARVEY TIMOTHY C.. Addison’s disease and the regulation of potassium: The role of insulin and aldosterone. Medical Hypotheses [online] 2007 January, 69(5):1120-1126 [viewed 22 May 2014] Available from: doi:10.1016/j.mehy.2007.02.023
  16. CARROLL MF, SCHADE DS. A practical approach to hypercalcemia. Am Fam Physician [online] 2003 May 1, 67(9):1959-66 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12751658
  17. MULS E, BOUILLON R, BOELAERT J, LAMBERIGTS G, VAN IMSCHOOT S, DANEELS R, DE MOOR P. Etiology of hypercalcemia in a patient with Addison's disease. Calcif Tissue Int [online] 1982, 34(6):523-6 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6819071
  18. MIELL J, WASSIF W, MCGREGOR A, BUTLER J, ROSS R. Life-threatening hypercalcaemia in association with Addisonian crisis. Postgrad Med J [online] 1991 Aug, 67(790):770-772 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399040
  19. DOWNIE WW, GUNN A, PATERSON CR, HOWIE GF. Hypercalcaemic crisis as presentation of Addison's disease. Br Med J [online] 1977 Jan 15, 1(6054):145-146 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1603923
  20. ADROGUé HORACIO J., MADIAS NICOLAOS E.. Hyponatremia. N Engl J Med [online] 2000 May, 342(21):1581-1589 [viewed 22 May 2014] Available from: doi:10.1056/NEJM200005253422107
  21. SMITH DIARMUID M., MCKENNA KIERAN, THOMPSON CHRISTOPHER J.. Hyponatraemia. Clin Endocrinol [online] 2000 June, 52(6):667-678 [viewed 22 May 2014] Available from: doi:10.1046/j.1365-2265.2000.01027.x
  22. LIAMIS GEORGE, MILIONIS HARALAMPOS J., ELISAF MOSES. Endocrine disorders: Causes of hyponatremia not to neglect. Ann Med [online] 2011 May, 43(3):179-187 [viewed 22 May 2014] Available from: doi:10.3109/07853890.2010.530680
  23. BISWAS M, DAVIES JS. Hyponatraemia in clinical practice Postgrad Med J [online] 2007 Jun, 83(980):373-378 [viewed 22 May 2014] Available from: doi:10.1136/pgmj.2006.056515
  24. TRIANTAFYLLOU PANAGIOTA, MAVRIDES PANAGIOTES, KATZOS GEORGEOS, PRINTZA NIKOLETA, PAPACHRISTOU FOTIOS. A girl with progressive fatigue and hyponatremia: question. Pediatr Nephrol [online] December, 25(11):2269-2269 [viewed 22 May 2014] Available from: doi:10.1007/s00467-009-1403-7
  25. ANNANE DJILLALI. Adrenal insufficiency in sepsis. CPD [online] 2008 July, 14(19):1882-1886 [viewed 22 May 2014] Available from: doi:10.2174/138161208784980626
  26. MARIK PE, ZALOGA GP. Adrenal insufficiency during septic shock. Crit Care Med [online] 2003 Jan, 31(1):141-5 [viewed 22 May 2014] Available from: doi:10.1097/01.CCM.0000044483.98297.89

Investigations - for Diagnosis

Fact Explanation
Complete blood count To investigate whether there is an underlying inflammation or infection. Lymphocytopenia also has been associated with Addisons disease and chronic steroid therapy. [1] [2]
Blood glucose level blood sugar at the admission. To exclude hypoglycemia. [3] [4]
Electrolyte levels In hypoadrenalism usually there is hyponatremia and hyperkalemia. [5] [6] [7] [8] [9]
Serum calcium There can be elevated serum calcium since volume depletion causes reduced glomerular filtration rate and excretion of calcium. [10] [11] [12]
Serum thyroxine level It's important to exclude hypothyroidism since it can mask hypoadrenalism. [13] [14] [15]
Serum cortisol level Emergency serum cortisol level should be measured on arrival [16] despite of diurnal variation of the hormone. [17] In Addisons disease serum free cortisol level is low. [18] The newer tendency is to measure salivary cortisol level as it's not an invasive method. [19] [20]
Tetracosactide test This is a test done by administering low dose synthetic ACTH (Synacthen, tetracosactide) and measuring the cortisol response in 30, 60, 90, and 120 minutes. It's diagnostic of Addisons disease, but should be performed only after the acute management has been done. [19] [20] [21] [22] [23]
Blood culture Blood cultures and maybe cultures from wounds etc should be assessed to exclude sepsis. [24] [25]
ECG To identify the effects of electrolyte abnormalities on cardiac function, main concern being hyperkalemia. [26] [27] [28]
Adrenal antibodies To diagnose autoimmune adrenalitis. [29] [30]
Chest X-ray To exclude pulmonary tuberculosis. [31]
Abdominal CT Usually to evaluate secondary causes of hypoadrenalism like calcifications, hemorrhages, or metastatic deposits. [32] [33] [34] [35] [36]
References
  1. GROENEVELD A. B. J., BOSSINK A. W. J., VAN MIERLO G. J., HACK C. E.. Circulating Inflammatory Mediators in Patients with Fever: Predicting Bloodstream Infection. Clinical and Vaccine Immunology [online] 2001 November, 8(6):1189-1195 [viewed 22 May 2014] Available from: doi:10.1128/CDLI.8.6.1189-1195.2001
  2. BLUMENREICH M.S. Chapter 153:The White Blood Cell and Differential Count. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition: [web] Available at http://www.ncbi.nlm.nih.gov/books/NBK261/
  3. KROMAH FATUMA, TYROCH ALAN, MCLEAN SUSAN, HUGHES HAROLD, FLAVIN NINA, LEE SOYOUNG. Relative Adrenal Insufficiency in the Critical Care Setting: Debunking the Classic Myth. World J Surg [online] December, 35(8):1818-1823 [viewed 21 May 2014] Available from: doi:10.1007/s00268-011-1126-3
  4. DIéGUEZ FELECHOSA MARTA, VALDéS GALLEGO NURIA, GARCíA-ALCALDE FERNáNDEZ MARíA LUISA, CASAL ALVAREZ FLORENTINO. Hypoglycemia as a manifestation of iatrogenic adrenal insufficiency due to topical steroids. Endocrinología y Nutrición [online] 2013 November, 60(9):e21-e22 [viewed 21 May 2014] Available from: doi:10.1016/j.endonu.2013.01.005
  5. LIAMIS GEORGE, MILIONIS HARALAMPOS J., ELISAF MOSES. Endocrine disorders: Causes of hyponatremia not to neglect. Ann Med [online] 2011 May, 43(3):179-187 [viewed 22 May 2014] Available from: doi:10.3109/07853890.2010.530680
  6. BISWAS M, DAVIES J S. Hyponatraemia in clinical practice. Postgraduate Medical Journal [online] 2007 June, 83(980):373-378 [viewed 22 May 2014] Available from: doi:10.1136/pgmj.2006.056515
  7. TRIANTAFYLLOU PANAGIOTA, MAVRIDES PANAGIOTES, KATZOS GEORGEOS, PRINTZA NIKOLETA, PAPACHRISTOU FOTIOS. A girl with progressive fatigue and hyponatremia: question. Pediatr Nephrol [online] December, 25(11):2269-2269 [viewed 22 May 2014] Available from: doi:10.1007/s00467-009-1403-7
  8. EL FASSI D., NIELSEN G.. Hyperkalemia: A Clue to the Diagnosis of Adrenal Insufficiency. Circulation [online] December, 128(24):2620-2621 [viewed 22 May 2014] Available from: doi:10.1161/CIRCULATIONAHA.113.005169
  9. MULS E, BOUILLON R, BOELAERT J, LAMBERIGTS G, VAN IMSCHOOT S, DANEELS R, DE MOOR P. Etiology of hypercalcemia in a patient with Addison's disease. Calcif Tissue Int [online] 1982, 34(6):523-6 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6819071
  10. MIELL J, WASSIF W, MCGREGOR A, BUTLER J, ROSS R. Life-threatening hypercalcaemia in association with Addisonian crisis. Postgrad Med J [online] 1991 Aug, 67(790):770-772 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399040
  11. DOWNIE WW, GUNN A, PATERSON CR, HOWIE GF. Hypercalcaemic crisis as presentation of Addison's disease. Br Med J [online] 1977 Jan 15, 1(6054):145-146 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1603923
  12. SHAIKH MG, LEWIS P, KIRK JMW. Thyroxine unmasks Addison's disease. [online] 2007 January, 93(12):1663-1665 [viewed 22 May 2014] Available from: doi:10.1111/j.1651-2227.2004.tb00860.x
  13. OSMAN IA, LESLIE P. Addison's disease. Adrenal insufficiency should be excluded before thyroxine replacement is started. BMJ [online] 1996 Aug 17, 313(7054):427 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2351808
  14. CHANG SHY-SHIN, LIAW SHIUMN-JEN, BULLARD MICHAEL J., CHIU TE-FA, CHEN JIH-CHANG, LIAO HOW-CHIN. Adrenal Insufficiency in Critically Ill Emergency Department Patients: A Taiwan Preliminary Study. Acad Emergency Med [online] 2001 July, 8(7):761-764 [viewed 22 May 2014] Available from: doi:10.1111/j.1553-2712.2001.tb00202.x
  15. CHAN S., DEBONO M.. Review: Replication of cortisol circadian rhythm: new advances in hydrocortisone replacement therapy. Therapeutic Advances in Endocrinology and Metabolism [online] December, 1(3):129-138 [viewed 22 May 2014] Available from: doi:10.1177/2042018810380214
  16. BAKER PETER R., NANDURI PRIYAANKA, GOTTLIEB PETER A., YU LIPING, KLINGENSMITH GEORGEANNA J., EISENBARTH GEORGE S., BARKER JENNIFER M.. Predicting the onset of Addison’s disease: ACTH, renin, cortisol and 21-hydroxylase autoantibodies. [online] December, 76(5):617-624 [viewed 22 May 2014] Available from: doi:10.1111/j.1365-2265.2011.04276.x
  17. RESTITUTO P., GALOFRé J.C., GIL M.J., MUGUETA C., SANTOS S., MONREAL J.I., VARO N.. Advantage of salivary cortisol measurements in the diagnosis of glucocorticoid related disorders. Clinical Biochemistry [online] 2008 June, 41(9):688-692 [viewed 22 May 2014] Available from: doi:10.1016/j.clinbiochem.2008.01.015
  18. TUNN S, MöLLMANN H, BARTH J, DERENDORF H, KRIEG M. Simultaneous measurement of cortisol in serum and saliva after different forms of cortisol administration. Clin Chem [online] 1992 Aug, 38(8 Pt 1):1491-4 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1643721
  19. BANGAR V, CLAYTON R.. How reliable is the short synacthen test for the investigation of the hypothalamic-pituitary-adrenal axis?. European Journal of Endocrinology [online] 1998 December, 139(6):580-583 [viewed 22 May 2014] Available from: doi:10.1530/eje.0.1390580
  20. AGWU JC, SPOUDEAS H, HINDMARSH PC, PRINGLE PJ, BROOK CG. Tests of adrenal insufficiency. Arch Dis Child [online] 1999 Apr, 80(4):330-3 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10086937
  21. PATON J. Adrenal responses to low dose synthetic ACTH (Synacthen) in children receiving high dose inhaled fluticasone. Archives of Disease in Childhood [online] 2006 October, 91(10):808-813 [viewed 22 May 2014] Available from: doi:10.1136/adc.2005.087247
  22. REIMONDO GIUSEPPE, BOVIO SILVIA, ALLASINO BARBARA, TERZOLO MASSIMO, ANGELI ALBERTO. Secondary hypoadrenalism. Pituitary [online] December, 11(2):147-154 [viewed 22 May 2014] Available from: doi:10.1007/s11102-008-0108-4
  23. SULIMAN ABDULWAHAB M., SMITH THOMAS P., LABIB MOURAD, FIAD TAREK M., MCKENNA T. JOSEPH. The low-dose ACTH test does not provide a useful assessment of the hypothalamic-pituitary-adrenal axis in secondary adrenal insufficiency. Clin Endocrinol [online] 2002 April, 56(4):533-539 [viewed 22 May 2014] Available from: doi:10.1046/j.1365-2265.2002.01509.x
  24. SHAH ZAFARAMIN, WANI FAYAZAHMAD, WAHID ABDUL, PARVEEN SHAHEENA, NAZIR ARJUMAND, MAQBOOL MUZAFFAR. Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock. Indian J Crit Care Med [online] 2009 December [viewed 23 May 2014] Available from: doi:10.4103/0972-5229.56054
  25. HATHERILL M., TIBBY S. M, HILLIARD T., TURNER C., MURDOCH I. A. Adrenal insufficiency in septic shock. Archives of Disease in Childhood [online] 1999 January, 80(1):51-55 [viewed 23 May 2014] Available from: doi:10.1136/adc.80.1.51
  26. SOMERVILLE W. The Effect of Potassium and Calcium on the Electrocardiogram Postgrad Med J [online] 1951 Jun, 27(308):296-302 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2530263
  27. OZCAN F, USTUN I, BERKER D, AYDIN Y, DELIBASI T, GULER S. Inverted T waves in patient with Addisonian crisis. J Natl Med Assoc [online] 2005 Nov, 97(11):1539-1540 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594907
  28. HARTOG M, JOPLIN GF. Effects of cortisol deficiency on the electrocardiogram. Br Med J [online] 1968 May 4, 2(5600):275-277 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1985838
  29. BAKALOV V.K.. Adrenal antibodies detect asymptomatic auto-immune adrenal insufficiency in young women with spontaneous premature ovarian failure. [online] 2002 August, 17(8):2096-2100 [viewed 22 May 2014] Available from: doi:10.1093/humrep/17.8.2096
  30. NIGAM R., BHATIA E., MIAO D., YU L., BROZZETTI A., EISENBARTH G. S., FALORNI A.. Prevalence of adrenal antibodies in Addison's disease among north Indian Caucasians. Clin Endocrinol [online] 2003 November, 59(5):593-598 [viewed 22 May 2014] Available from: doi:10.1046/j.1365-2265.2003.01889.x
  31. PATNAIK MM, DESHPANDE AK. Diagnosis--Addison's disease secondary to tuberculosis of the adrenal glands. Clin Med Res [online] 2008 May, 6(1):29 [viewed 23 May 2014] Available from: doi:10.3121/cmr.2007.754a
  32. PATNAIK M. M., DESHPANDE A. K.. Diagnosis-Addison's Disease Secondary to Tuberculosis of the Adrenal Glands. Clinical Medicine & Research [online] 2008 May, 6(1):29-29 [viewed 22 May 2014] Available from: doi:10.3121/cmr.2007.754a
  33. WOLVERSON MK, KANNEGIESSER H. CT of bilateral adrenal hemorrhage with acute adrenal insufficiency in the adult. AJR Am J Roentgenol [online] 1984 Feb, 142(2):311-4 [viewed 22 May 2014] Available from: doi:10.2214/ajr.142.2.311
  34. PROVENZALE JM, ORTEL TL, NELSON RC. Adrenal hemorrhage in patients with primary antiphospholipid syndrome: imaging findings. AJR Am J Roentgenol [online] 1995 Aug, 165(2):361-4 [viewed 22 May 2014] Available from: doi:10.2214/ajr.165.2.7618557
  35. KUMAR RAKESH, SHAMIM SHAMIM AHMED, SHANDAL VARUN, SHARMA PUNIT, GADODIA ANKUR, MALHOTRA ARUN. FDG PET/CT in Detection of Adrenal Metastasis in Patients With Renal Cell Carcinoma. Clinical Nuclear Medicine [online] 2011 July, 36(7):513-517 [viewed 22 May 2014] Available from: doi:10.1097/RLU.0b013e3182175435
  36. 36. DO YOUNG ROK, SONG HONG SUK, KIM IN HO. Adrenalectomy for Metastatic Disease to the Adrenal Gland from Gastric Cancer: Report of a Case. Korean J Intern Med [online] 2007 December [viewed 22 May 2014] Available from: doi:10.3904/kjim.2007.22.1.18

Investigations - Followup

Fact Explanation
Cortisol level Checking serum cortisol levels fequently and re-adjusting the dose of hydrocortisone/ fludrocortisone level until it replaces the natural level. [1] [2] It can be tested in serum or saliva. [3] Individual adjustment of glucocorticoids to approach normal cortisol concentrations during the day can reduce overreplacement, especially in the evening. This can lead to a reduction of sleep disturbances and fatigue in patients with Addison's disease. [4]
Serum electrolytes Since symptomatic adrenal insufficiency causes hyponatremia [5] and hyperkalemia [6] it's important to asses whether the patient has been treated with adequate mineralocorticoids by checking serum sodium and potassium frequently.
Blood glucose level Over-treatment with glucocorticoids can cause hyperglycemia [7] [8] and adrenal insufficiency or under-treatment can cause hypoglycemia. [9] The autoimmune causes of Addisons can cause type I diabetes mellitus. [10] [11] [12]
References
  1. BAXTER M, GORICK S, SWORDS F M. Recovery of adrenal function in a patient with confirmed Addison's disease. EDM [online] 2013 December [viewed 25 May 2014] Available from: doi:10.1530/EDM-13-0070
  2. CHAKERA A. J., VAIDYA B.. Spontaneously resolving Addison's disease. QJM [online] December, 105(11):1113-1115 [viewed 25 May 2014] Available from: doi:10.1093/qjmed/hcr162
  3. RESTITUTO P., GALOFRé J.C., GIL M.J., MUGUETA C., SANTOS S., MONREAL J.I., VARO N.. Advantage of salivary cortisol measurements in the diagnosis of glucocorticoid related disorders. Clinical Biochemistry [online] 2008 June, 41(9):688-692 [viewed 25 May 2014] Available from: doi:10.1016/j.clinbiochem.2008.01.015
  4. SMANS L, LENTJES E, HERMUS A, ZELISSEN P. Salivary cortisol day curves in assessing glucocorticoid replacement therapy in Addison's disease. Hormones (Athens) [online] 2013 Jan-Mar, 12(1):93-100 [viewed 25 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23624135
  5. BISWAS M, DAVIES J S. Hyponatraemia in clinical practice. Postgraduate Medical Journal [online] 2007 June, 83(980):373-378 [viewed 25 May 2014] Available from: doi:10.1136/pgmj.2006.056515
  6. EL FASSI D., NIELSEN G.. Hyperkalemia: A Clue to the Diagnosis of Adrenal Insufficiency. Circulation [online] December, 128(24):2620-2621 [viewed 22 May 2014] Available from: doi:10.1161/CIRCULATIONAHA.113.005169
  7. KWON SOONHO, HERMAYER KATHIE L.. Glucocorticoid-Induced Hyperglycemia. The American Journal of the Medical Sciences [online] 2013 April, 345(4):274-277 [viewed 26 May 2014] Available from: doi:10.1097/MAJ.0b013e31828a6a01
  8. CLORE JOHN N., THURBY-HAY LINDA. Glucocorticoid-Induced Hyperglycemia. Endocrine Practice [online] December, 15(5):469-474 [viewed 26 May 2014] Available from: doi:10.4158/EP08331.RAR
  9. NIEMAN LYNNETTE K., CHANCO TURNER MARIA L.. Addison's disease. Clinics in Dermatology [online] 2006 July, 24(4):276-280 [viewed 26 May 2014] Available from: doi:10.1016/j.clindermatol.2006.04.006
  10. GLYNN NIGEL, BASHIR MOHAMMED, SMITH DIARMUID, THOMPSON CHRISTOPHER J. Newly diagnosed type 1 diabetes presenting with hypoglycemia due to simultaneous presentation of Addison's disease. Pediatr Diabetes [online] December:n/a-n/a [viewed 26 May 2014] Available from: doi:10.1111/pedi.12113
  11. THOMAS JAMES B., PETROVSKY NIKOLAI, AMBLER GEOFFREY R.. Addison's disease presenting in four adolescents with type 1 diabetes. Pediatr Diabetes [online] 2004 December, 5(4):207-211 [viewed 26 May 2014] Available from: doi:10.1111/j.1399-543X.2004.00056.x
  12. MCAULAY V.. Addison's disease in type 1 diabetes presenting with recurrent hypoglycaemia. [online] 2000 April, 76(894):230-232 [viewed 26 May 2014] Available from: doi:10.1136/pmj.76.894.230

Management - General Measures

Fact Explanation
Securing the airway, breathing and circulation. In the patients who present with acute weakness, syncope or patients with cardiovascular demise, ABC approach should be taken. [1] [2] [3] [4]
Patient education Educating the patients and his/her family regarding the illness and it's precipitating factors together with the importance of adherence to treatments can improve the quality of life. [5] [6] [7]
Avoidance of precipitating factors The risk factors for developing a crisis in chronic Addisons disease patients should be identified and taught to avoid. i. e. acute drug withdrawal, untreated infections, surgery etc. [8] [9]
Assess cardiovascular status and electrolytes frequently. Once the patient is euadrenal, follow-up examinations and investigations to maintain the desirable blood pressure and electrolytes, with frequent (preferably once a month) overall assessment should be done. [10] [11]
References
  1. BRICE J. Early management of unconscious patients. Proc R Soc Med [online] 1972 Jul, 65(7):613 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1644223
  2. ROBINSON N, MACLEOD KG. Airway management in the transfer of the unconscious patient. Ann R Coll Surg Engl [online] 1983 Nov, 65(6):372-373 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2494423
  3. ANDREW J. Tracheostomy, and Management of the Unconscious Patient Br Med J [online] 1956 Aug 11, 2(4988):328-332 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2035090
  4. THIM TROELS, KRARUP , GROVE , ROHDE , LOFGREN . Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. IJGM [online] 2012 January [viewed 22 May 2014] Available from: doi:10.2147/IJGM.S28478
  5. CHAKERA ALI J., VAIDYA BIJAY. Addison Disease in Adults: Diagnosis and Management. The American Journal of Medicine [online] 2010 May, 123(5):409-413 [viewed 23 May 2014] Available from: doi:10.1016/j.amjmed.2009.12.017
  6. HUSEBYE E. S., ALLOLIO B., ARLT W., BADENHOOP K., BENSING S., BETTERLE C., FALORNI A., GAN E. H., HULTING A.-L., KASPERLIK-ZALUSKA A., KäMPE O., LøVåS K., MEYER G., PEARCE S. H.. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med [online] December, 275(2):104-115 [viewed 23 May 2014] Available from: doi:10.1111/joim.12162
  7. NAPIER CATHERINE, PEARCE SIMON H.S.. Autoimmune Addison's disease. La Presse Médicale [online] 2012 December, 41(12):e626-e635 [viewed 23 May 2014] Available from: doi:10.1016/j.lpm.2012.09.010
  8. OMORI KAZUE, NOMURA KAORU, SHIMIZU SATORU, OMORI NARIKO, TAKANO KAZUE. Risk Factors for Adrenal Crisis in Patients with Adrenal Insufficiency. Endocr J [online] 2003 December, 50(6):745-752 [viewed 23 May 2014] Available from: doi:10.1507/endocrj.50.745
  9. HAHNER S., LOEFFLER M., BLEICKEN B., DRECHSLER C., MILOVANOVIC D., FASSNACHT M., VENTZ M., QUINKLER M., ALLOLIO B.. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. European Journal of Endocrinology [online] December, 162(3):597-602 [viewed 23 May 2014] Available from: doi:10.1530/EJE-09-0884
  10. JODAR ESTEBAN, VALDEPENAS MARIA PILAR RUIZ, MARTINEZ GUILLERMO, JARA ANTONINO, HAWKINS FEDERICO. Long-term follow-up of bone mineral density in Addison's disease. Clin Endocrinol [online] 2003 May, 58(5):617-620 [viewed 23 May 2014] Available from: doi:10.1046/j.1365-2265.2003.01761.x
  11. HUSEBYE E. S., ALLOLIO B., ARLT W., BADENHOOP K., BENSING S., BETTERLE C., FALORNI A., GAN E. H., HULTING A.-L., KASPERLIK-ZALUSKA A., KäMPE O., LøVåS K., MEYER G., PEARCE S. H.. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med [online] December, 275(2):104-115 [viewed 23 May 2014] Available from: doi:10.1111/joim.12162

Management - Specific Treatments

Fact Explanation
Correct fluid status. Prompt and aggressive fluid resuscitation is an important initial step because the patients may be severely dehydrated with low blood pressure. [1] [2]
Correct hypoglycemia. Adrenal crisis can be associated with hypoglycemia which can in turn make electrolyte abnormalities even worse, so it's important to correct the blood glucose status. [3] [4]
Correct electrolyte status. Hyponatremia and hyperkalemia are well recognized electrolyte abnormalities in Addisons disease. Hypercalcemia is also a complication in severe dehydration. All the electrolytes should be corrected but special attention should be given to the potassium status since small changes affect the cardiac and neurological status. [5] [6] [7] [8]
Steroid replacement. Steroid replacement is life-saving in adrenal crisis. At the presentation, a bolus of intravenous hydrocortisone with maintenace steroid as oral hydrocortisone 15-25 mg/day in divided doses (dose monitoring based on the clinical judgement) Fludrocortisone 0.05-0.2 mg/day is given for substitution in mineralocorticoid deficiency aiming at normotension, normokalaemia and a plasma renin activity in the upper normal range. Continuos monitoring is essential. [9] [10] [11] [12] [13]
References
  1. ARLT WIEBKE. The Approach to the Adult with Newly Diagnosed Adrenal Insufficiency. The Journal of Clinical Endocrinology & Metabolism [online] 2009 April, 94(4):1059-1067 [viewed 22 May 2014] Available from: doi:10.1210/jc.2009-0032
  2. SHULMAN D. I., PALMERT M. R., KEMP S. F.. Adrenal Insufficiency: Still a Cause of Morbidity and Death in Childhood. PEDIATRICS [online] December, 119(2):e484-e494 [viewed 22 May 2014] Available from: doi:10.1542/peds.2006-1612
  3. JIALAL I, DESAI RK, MAHARAJ IC, PALA AS, JOUBERT SM. Isolated adrenocorticotrophic hormone (ACTH) deficiency associated with acute adrenal crisis. Postgrad Med J [online] 1985 May, 61(715):423-5 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2991871
  4. FISCHER JE, STALLMACH T, FANCONI S. Adrenal crisis presenting as hypoglycemic coma. Intensive Care Med [online] 2000 Jan, 26(1):105-8 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10663290
  5. TRUSZKOWSKI R, ZWEMER RL. Cortico-adrenal insufficiency and potassium metabolism Biochem J [online] 1936 Aug, 30(8):1345-1353 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1263191
  6. SOWDEN JM, BORSEY DQ. Hyperkalaemic periodic paralysis: a rare presentation of Addison's disease. Postgrad Med J [online] 1989 Apr, 65(762):238-240 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429272
  7. MUSHIYAKH YELENA, DANGARIA HARSH, QAVI SHAHBAZ, ALI NOORJAHAN, PANNONE JOHN, TOMPKINS DAVID. Treatment and pathogenesis of acute hyperkalemia. Journal of Community Hospital Internal Medicine Perspectives [online] 2012 January [viewed 22 May 2014] Available from: doi:10.3402/jchimp.v1i4.7372
  8. VAIDYA C., HO W., FREDA B. J.. Management of hyponatremia: Providing treatment and avoiding harm. Cleveland Clinic Journal of Medicine [online] December, 77(10):715-726 [viewed 22 May 2014] Available from: doi:10.3949/ccjm.77a.08051
  9. CHAKERA ALI J., VAIDYA BIJAY. Addison Disease in Adults: Diagnosis and Management. The American Journal of Medicine [online] 2010 May, 123(5):409-413 [viewed 22 May 2014] Available from: doi:10.1016/j.amjmed.2009.12.017
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