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Adrenal Insufficiency, Addison's disease, Addison's Crisis

Definition: Acute adrenal crisis is an extreme life-threatening manifestation of adrenal insufficiency. It occurs secondary to interruption of a normal or hyperfunctioning adrenal or pituitary gland or sudden interruption of adrenal replacement therapy.
Addison-crisis

Classification
Adrenal insufficiency can be divided into 3 categories:
  1.  chronic primary adrenal insufficiency (Addison disease)
  2.  chronic secondary adrenal insufficiency
  3.  and adrenal crisis (acute adrenal insufficiency).

Addison disease 

       causes :
  • Autoimmune in 80 % of cases
  • Infections (T.B. , HIV)
  • Metastases

 Chronic secondary adrenal insufficiency (-- ACTH)


caused by pituitary tumour

Adrenal crisis

 causes :
  • Sudden withdrawal of chronic steroids usage (or secondary to stress)
  • Adrenal hge (caused by,meningiococci-sepsis-warfarin therapy-coagulopathy)
  • Pituitary dysfunction (sheehan syndrome)
  • CNS lesions in rare cases         

Clinical manifestations of adrenal crisis

  • Unexplained hypotension (resistant to fluid and catecholamines)  
  • nonspecific symptoms such as anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, fever, confusion, or coma.

Treatment    

Immediate treatment of adrenal crisis should begin prior to laboratory confirmation (usually hyperkalemia,hyponatremia)

  • Normal saline is the intravenous fluid of choice
  • Stress-dose steroid replacement should be administered. Hydrocortisone may be administered as a 100-mg intravenous push followed by continuous infusion of 150-300 mg/day for 2 to 3 days
  • Alternatively, dexamethasone as a 4-mg intravenous bolus may be administered instead of hydrocortisone to avoid interference with testing of cortisol levels
  • Mineralocorticoid, namely fludrocortisone acetate, should also be administered at 0.1 mg daily. 


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