Adrenal crisis

Revision as of 22:50, 18 December 2018 by Rossdonaldson1 (talk | contribs) (Management)


  • Consider in any patient with unexplained hypotension (especially in those with HIV or taking exogenous steroids)
  • Generally caused by mineralocorticoid deficiency, not glucocorticoid deficiency
    • This is the reason crises occur much more frequently with primary adrenal insufficiency

Causes (Adrenal Insufficiency)

  • Primary adrenal insufficiency (decreased cortisol and aldosterone)
    • Autoimmune (70%)
    • Adrenal hemorrhage
      • Coagulation disorders
      • Sepsis (Waterhouse-Friderichsen syndrome)
    • Meds
    • Infection (HIV, TB)
      • TB is most common worldwide cause primary adrenal insuffiency
    • Sarcoidosis/amyloidosis
    • Mets
    • CAH
  • Secondary adrenal insufficiency (decreased ACTH → decreased cortisol only)
    • Withdrawal of steroid therapy
    • Pituitary disease
    • Head trauma
    • Postpartum pituitary necrosis
    • Infiltrative disorders of pituitary or hypothalamus


  • Increased demand
    • Infection
    • MI
    • Surgery
    • Trauma
  • Decreased supply
    • Discontinuation of steriod therapy

Clinical Features

Differential Diagnosis




Begin treatment immediately in any suspected case (prognosis related to rapidity of treatment)

  • Treat underlying cause, if known
  • IVF - D5NS 2-3L (corrects fluid deficit and hypoglycemia)
  • Steroids
  • Vasopressors
    • Administer after steroid therapy in patients unresponsive to fluid resuscitation

Stress-Dose Steroids in Illness

To aid in mounting stress response in those with adrenal insufficiency lacking endogenous cortisol

Illness Type Steroid Administration
Minor, with fever < 38°C Double dose of chronic maintenance steroids
Severe, with fever > 38°C Triple dose of chronic maintenance steroids
Vomiting, listless, or hypotensive Hydrocortisone at 1-2mg/kg (as above in adrenal crisis)


  • Admit

See Also


  1. Nutman TB. Evaluation and differential diagnosis of marked, persistent eosinophilia. Immunol Allergy Clin North Am. 2007 Aug; 27(3): 529–549.
  2. Wilson TA et al. Adrenal Hypoplasia Medication. eMedicine. Feb 11, 2013.