Endocrine Abstracts

Introduction: An Addison’s crisis is a life-threatening situation that usually results hypotension/hypovolemic shock, nausea or vomiting, fever, loss of consciousness, hyponatremia (Na ≤132 mmol/l), hyperkalemia and hypoglycemia.

Case description: 33 years old patient was found at home after firefighters broke down the door, with a lot of stomach contents around. The last contact with relatives was a day ago, when the patient complained of fever and vomiting. The patient was unconscious, hypotensive (BP 72/48mmHg), glycemia 5.2 mmol/l, hyperkalemia 6.5 mmol/l, normonatremia 137 mmol/l, increased uremic indicators (creatinine concentration in serum 1439 mcmol/l ; urea 29.3 mmol/l), increased CRB 284.8 mg/l, elevated creatine kinase activity 981 IU/l was found. CT of the head, Ro of the lungs, ultrasound of the abdomen - without changes, and neuroinfection was ruled out. The patient was hospitalized in the intensive care unit, treatment with dexamethasone, infusion and antibiotic therapy was started. Renal replacement therapy was started due to significant uremic indicators. Hyperpigmentation of the patient’s skin was observed, so primary adrenal insufficiency was suspected, ACTH was 6.7 pmol/l (n. 1.63 - 14.15 pmol/l) and cortisol in the morning was 25.7 nmol/l (less than 12 hours after dexamethasone injection). After the hypovolemic shock regressed, without administering glucocorticoids for 2 days, the tests were repeated: ACTH - 374.5 pmol/and cortisol - 56.91 nmol/l - primary adrenal insufficiency was confirmed and continuous treatment with hydrocortisone was started, gradually reducing the doses to maintenance doses. In case of a tendency to hyponatremia and hypotension, fludrocortisone was added to hydrocortisone. Renal function and electrolyte imbalance were fully restored, inflammatory indicators normalized. The patient tested for other autoimmune diseases - confirmed chronic autoimmune thyroiditis with euthyroidism. Anti-GAD and anti-IA2 were also positive, but there are currently no data for diabetes. The autoimmune polyglandular syndrome (APS-2) was diagnosed.

Conslusion: In untreated Addison’s disease, stress such as trauma, infection, or illness can lead to an Addison’s crisis. Immediate treatment with intravenous hydrocortisone is recommended for patients with suspected adrenal crisis without waiting for test results.

References: 1. Ramya Punati, Raquel Kristin S. Ong, Stefan Bornstein, 2021. Acute Adrenal Insufficiency. Endocrine Emergencies 154-165.2. Allolio B. Extensive expertise in endocrinology. Adrenal crisis. Eur J Endocrinol 2015 Mar;172(3):R115-24.