Crisis adrenal

An Addisonian crisis (adrenal insufficiency) is a complication that may occur... 

During an acute adrenal crisis, the immediate treatment goals are to correct volume depletion, manage hypoglycemia, and provide glucocorticoid replacement. 

Clinical Presentation and Diagnosis of Acute Adrenal Insufficiency (Adrenal Crisis)1,3,4 ... 

The unstimulated serum cortisol and rapid ACTH stimulation tests are useful in the diagnosis of adrenal crisis (Table 42-2). The insulin tolerance test is contraindicated owing to preexisting hypoglycemia. The metyrapone test is also contraindicated because metyrapone inhibits cortisol production. 

Note Given the life-threatening nature of this condition, empirical treatment should be started before laboratory confirmation in patients who present with the clinical picture of an acute adrenal crisis. 

In patients presenting with acute adrenal crisis who have not been diagnosed previously with adrenal insufficiency, immediate treatment with injectable hydrocortisone and intravenous saline and dextrose solutions should be initiated prior to confirmation of the diagnosis because of the life-threatening nature of this condition. Determine and correct the underlying cause of the acute adrenal crisis (e.g., infection). 

How to prevent an acute adrenal crisis (adhere to therapy, and do not stop glucocorticoid treatment abruptly). There may be a need to increase the dose of glucocorticoid during excessive physiologic stress. 

Administration of parenteral glucocorticoid during an acute adrenal crisis. 

To Prevent Hypocortisolism and Development of Adrenal Insufficiency or Adrenal Crisis... 

Acute adrenal insufficiency (also known as adrenal crisis or Addisonian crisis) represents a true endocrine emergency. 

The most common cause of adrenal crisis is abrupt withdrawal of exogenous glucocorticoids in patients receiving chronic treatment that resulted in hypothalamic-pituitary-adrenal-axis suppression. 

Autoimmune polyglandular syndrome-Chron c autoimmune thyroiditis may occur in association with other autoimmune disorders. Treat patients with concomitant adrenal insufficiency with replacement glucocorticoids prior to initiation of treatment. Failure to do so may precipitate an acute adrenal crisis when thyroid hormone therapy is initiated. Patients with diabetes mellitus may require upward adjustments of their antidiabetic therapeutic regimens. Nontoxic diffuse goiter or nodular thyroid disease Use caution when administering levothyroxine to patients with nontoxic diffuse goiter or nodular thyroid disease in order to prevent precipitation of thyrotoxicosis. If the serum TSH is already suppressed, do not administer levothyroxine. 

Pseudoephedrine (Sudafed, Novafed, Afrinol, Others) [OTC] [Decongestant/Sympothomimetic] Uses Deconge tant Action Stimulates a-adren gic rec tors w/ vasoconstriction Dose Adults. 30-60 mg PO q6—8h Peds. 4 mg/kg/24 h PO qid -1- in renal insuff Caution [C, +] Contra Poorly controlled HTN or CAD, w/MAOIs Disp Tabs, caps, Liq SE HTN, insomnia, tach, arrhythmias, nervousness, tremor Interactions T Risk of HTN crisis W/ MAOIs T effects W/BBs, sympathomimetics X effects W/TCAs -1- effect OF methyldopa, reserpine EMS Found in many OTC cough/cold pr >arations use sympathomimetics w/ caution, may T adverse effects OD May cause N/V, HTN, arrhythmias, and Szs symptomatic and supportive... 

IV.a.1.9. Adrenal suppression. It results from inhibition of pituitary ACTH secretion, and some suppression of the normal adrenal response to stress may persist for years after stopping therapy. Rapid withdrawal of corticosteroid therapy can therefore precipitate dangerous acute adrenal insufficiency ( Addisonian crisis , with hypotension, vomiting, coma and ultimately death), and for this reason steroid treatment should always be reduced gradually, sometimes over many months, according to the dose and duration of therapy. 

When first seen, the infant with congenital adrenal hyperplasia may be in acute adrenal crisis and should be treated as described above, using appropriate electrolyte solutions and an intravenous preparation of hydrocortisone in stress doses. 

Infants with salt-losing crisis and adrenal insufficiency in infancy may have adrenal hypoplasia congenita. This can be of two types recessive, for which the cause has not been defined and which affects mostly the fetal zone, and X-linked, which is caused by mutations in the DAX-1 gene, which (with steroidogenic factor-1) controls definitive zone development and steroidogenesis [71]. GC-MS analysis of patients with the disorder show variant patterns from absence of neonatal A5 steroids, appropriate for the recessive form [81], to extremely low cortisol production and transient 11/Lhy-droxylase deficiency, as evidenced through increased THS excretion (Malunowicz, personal communication). 

An acute adrenal crisis occurred in a woman who received an intra-articular glucocorticoid for pseudogout of the knee (464). 

An 87-year-old woman received intra-articular betamethasone (Diprophos) 7 mg on three occasions for painful knee joints over 6 months. Six weeks after the last injection she developed diffuse pain and contractures in the legs, fatigue, nausea, abdominal pain, and weight loss of 6 kg. Both knee joints were tender but there was no effusion. Her serum sodium concentration was 123 mmol/1, serum osmolality 254 mosmol/kg, urine sodium 136 mmol/1, and urinary osmolality 373 mosmol/kg. The syndrome of inappropriate antidiuretic hormone secretion was diagnosed, but despite treatment she remained drowsy and hyponatremic. About a week later, she developed hypotension and symptoms of an acute abdomen. Further investigations showed that her basal cortisol concentration was low (36 nmol/1) but it increased to 481 nmol/1 after a short tetracosactide test, consistent with acute adrenal crisis. She recovered rapidly after treatment with oral hydrocortisone, but still required glucocorticoid substitution several months later. 

Wicki J, Droz M, Cirafici L, Vallotton MB. Acute adrenal crisis in a patient treated with intraarticular steroid therapy. J Rheumatol 2000 27(2) 510-1. 

Todd GR, Acerini CL, Buck JJ, Murphy NP, Ross-Russell R, Warner JT, McCance DR. Acute adrenal crisis in asthmatics treated with high-dose fluticasone propionate. Eur Respir J 2002 19(6) 1207-9. 

Todd GR, Acerini CL, Ross-Russell R, Zahra S, Warner JT, McCance D. Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom. Arch Dis Child 2002 87(6) 457-61. 

Acute adrenal hemorrhage, either unilateral (17) or bilateral (18), has been observed repeatedly after corticotropin administration, and causes an acute abdominal crisis. Although it is usually seen in children, hemorrhage can also occur in adults (SEDA-17, 451). 

Adrenal insufficiency can be associated with hypothyroidism (either by autoimmune destruction or due to hypophyseal disease) and carries the risk of acute Addisonian crisis if thyroid substitution precedes glucocorticoid therapy. The diagnostic problem presented by the fact that a few patients with central hypothyroidism have a moderately increased serum TSH should be kept in mind (62). 

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