https://meditropics.com/unusual-maifestations-of-adrenal-crisis/

Bindu Kulshreshtha
Head of department, Department of Endocrinology, ABVIMS & Dr. RML Hospital, New Delhi                             

Adrenal crisis is not uncommon among patients presenting to the Medical Emergencies. 1 in 12 patients diagnosed with primary adrenal insufficiency carries the risk of Adrenal crises the subsequent year. The usual presentation is that of a dehydrated patient with hypovolemic shock not responding to standard therapy along with hyponatremia and hyperkalemia. The correct diagnosis is quite rewarding since institution of steroids results in prompt restoration of body functions and prevents an otherwise potentially lethal condition. The correct diagnosis may however be missed unless one has a keen eye and awareness about myriad presentations of adrenal crises.

Since patients may present with gastrointestinal symptoms along with diarhoea and vomiting, the patient may initially be treated as acute gastroenteritis. Since infections may be the precipitating cause for adrenal crises in a patient having subnormal adrenal function, the patient may be initially considered to be in septic shock. Some patients may develop cardiomyopathy with low Ejection Fraction associated with adrenal insufficiency. Some patients may also have ECG abnormalities related to adrenal insufficiency.

Uncommonly patients with Adrenal Insufficiency may present with psychiatric symptoms. Neuropsychiatric symptoms of AD include, but are not limited to, depression, lack of energy, and sleep disturbances. During an Addisonian crisis, agitation, delirium, and, in some cases, visual and auditory hallucinations are reports Neuro psychiatric symptoms might also be the first presentation of an Addisonian crisis. The diagnosis in these cases is usually delayed till a referral to a physician or endocrinologist is sought for electrolyte abnormalities. Some Patients may also present with acute hypercalcemia which is usually a consequence of Dehydration , decreased renal excretion and bone resorption.

Treatment involves intravenous hydrocortisone or hydrocortisone infusion along with fluid replacement with Normal Saline. In spite of remarkable improvement in the general condition of the patient, adrenal insufficiency is associated with morbidity. Educating the patient regarding sick day rules, stress dosing of steroids, need for injectable steroids is important and may prevent potentially lethal crises in future.