Endocrine Abstracts

Introduction: Hen corticosteroids are utilised for their anti-inflammatory properties, adrenocortical atrophy may result. Abrupt steroid withdrawal or intercurrent illness can precipitate acute adrenal crisis. We report two cases of adrenal crisis which resulted from withdrawal of immunosuppressive steroid therapy.

Case report: i) A 74-year-old gentleman was admitted with hypotension (BP 80/40), severe hyponatremia (Na:118 mmol/l) and acute renal failure (Creat 470 mmol/l). Despite i.v. fluids, hypotension (70/46) and renal failure (Creat 610) deteriorated; dialysis was recommended. Endocrinology consultation, for hyponatremia, elicited a drug history of prednisolone 5 mg daily for rheumatoid arthritis. The patient was treated with i.v. hydrocortisone 100 mg i.v. qds, with rapid recovery of BP (134/80), and plasma sodium (137 mmol/l). Further history revealed that prednisolone had been withheld during 48 h of bowel preparation for colonoscopy, after which the patient vomited and became delirious. The patient was unaware of ‘sick day rules’ and had no medicalert bracelet. ii) A 76-year-old lady was admitted for knee arthroscopy. Post operatively her plasma sodium dropped from 142 to 119 mmol/l. BP fell to 102/58 mmHg. An endocrinology consult for hyponatraemia documented that she was on prednisolone 5 mg daily for rheumatoid arthritis, but had run out of tablets 3 days prior to her admission. She had no i.v. hydrocortisone cover for anaesthesia. Random cortisol was <30 nmol/l. A diagnosis of adrenal crisis due to steroid withdrawal was made. She rapidly responded to i.v. hydrocortisone, and plasma sodium rose to 130 mmol/l over 36 h. The patient was unaware of ‘sick day rules’ and had no medicalert bracelet.

Conclusion: The case studies illustrate the vulnerability to adrenal crisis in patients on long-term immunosuppressive steroid. Patients on immunosuppressive steroids should be as aware of sick day rules as endocrine patients on adrenal replacement therapy.