Suggested by Geoffery Bellhouse, for LondonEM.
A 57 year-old female with a previous medical history of Rheumatoid Arthritis (RA) on Adalimumab and Glucocorticoid therapy presents to the ED for weakness and lethargy. The patient denies chest pain and shortness of breath. She denies a familial history of coronary artery disease, smoking, hypertension, hyperlipidemia, diabetes, and a personal/familial history of thyroid pathology. ROS is negative for recent hospitalization, recent illness, sick contacts, and foreign travel.
Vital Signs: HR 135, BP 81/62, RR 18, T103.1 Oral, SpO2 97% room air.
Physical exam: Toxic appearing obese female, GCS 15, A&O x3, no focal neurologic deficits, lungs CTAB, abdomen benign.
ECG: Sinus Tachycardia, normal axis, no acute ST-T wave changes.
Two peripheral IVs are obtained. Fluid resuscitation and broad-spectrum antibiotics are initiated. VBG reveals a lactate of 4.2UA: nitrite positive, leukocyte esterase positive, 3+ bacteria.
After 2L of NS, the patient’s HR is 131, her BP 80/63.
Norepinephrine is initiated with minimal improvement in her MAP.
What do you suspect as a diagnosis?
What’s the next step in your evaluation and treatment?
Answer: Acute Adrenal Insufficiency1-3
- Precipitating Causes: Acute stress or illness in any patient who has been receiving glucocorticoid therapy or in those diagnosed with conditions associated with adrenal insufficiency (metastatic cancer, AIDS, tuberculosis).
- May also be a manifestation of previously undiagnosed chronic adrenal insufficiency.
- Presentation: Consider in individuals with unexplained fever, abdominal pain, and orthostatic hypotension, or in patients experiencing shock refractory to vasopressors.
Utilize the H&P to direct evaluation and treatment (rule out underlying etiologies: infection, myocardial infarction, etc.)
Accucheck: evaluate for hypoglycemia
FBC: normochromic, normocytic anemia; relative lymphocytosis common
VBG: frequently mild metabolic acidosis
U&E: pre-renal azotemia
Primary adrenal insufficiency: look for hyponatremia and hyperkalemia
Secondary adrenal insufficiency: look for hyponatremia
50-100mg hydrocortisone IV or IM every 6 hours1
If adrenal insufficiency is suspected, initiate glucocorticoid therapy as soon as possible.
Improvement following steroid administration suggests the diagnosis.
A random serum cortisol level is of little utility: Cortisol is released in a pulsatile fashion demonstrating diurnal variation; The administration of etomidate has been shown to decrease cortisol production; Hypoalbuminemia (common in the critically ill) lowers cortisol-binding globulin (CBG) resulting in a decreased total cortisol measurement.
Corticosyn/Synacthen (Synthetic ACTH) Stimulation Testing is the standard screening test for diagnosis and should be considered upon specialty consultation. Hydrocortisone therapy should be continued until stimulation testing is performed.
EM@3AM – Acute Adrenal Insufficiency
Barthel A, Willenberg H, Gruber M, Bornstein S. In: Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, Saunders Elsevier. 2016; 1763-1774.e.4.
El Fassi D, Nielsen G. Hyperkalemia: A clue to the diagnosis of adrenal insufficiency. Circulation. 2013; 128: 2620-2621.
Hamrahian A, Oseni T, Arafah B. Measurements of serum free cortisol in critically ill patients. N Engl J Med. 2004; 350: 1629-1638.