Endocrine · Year 2 · from Endocrine

Case 2: Adrenal Crisis in a Patient on Chronic Glucocorticoids

Patient Demographics

• Age: 58 years
• Sex: Male
• Occupation: Accountant

Chief Complaint

"I feel extremely weak and dizzy. I think I'm going to pass out."

History of Present Illness

A 58-year-old man with polymyalgia rheumatica on chronic prednisone therapy presents with acute weakness, dizziness, nausea, vomiting, and abdominal pain. He has been taking prednisone 15 mg daily for 2 years for polymyalgia rheumatica. One week ago, his rheumatologist tapered his prednisone from 15 mg to 5 mg daily because his symptoms were well-controlled. Three days ago, he developed acute gastroenteritis with vomiting and diarrhea, and he has been unable to keep his prednisone down. This morning, he felt so weak he could barely get out of bed. His wife notes he appears confused.

Past Medical History

• Polymyalgia rheumatica (2 years, on chronic prednisone)
• Type 2 diabetes
• Hypertension
• No history of adrenal disease

Medications (Prior to Illness)

• Prednisone 5 mg daily (recently tapered from 15 mg)
• Metformin 1000 mg BID
• Lisinopril 20 mg daily

Physical Examination

• Vital Signs: BP 78/52 mmHg, HR 112 bpm, T 37.2C, orthostatic (unable to stand)
• General: Appears acutely ill, lethargic, weak
• Skin: No hyperpigmentation (unlike primary adrenal insufficiency)
• Cardiovascular: Tachycardic, regular rhythm, weak peripheral pulses
• Abdomen: Diffuse tenderness, hypoactive bowel sounds
• Neurologic: Lethargic but arousable, oriented x 2

Workup

• BMP: Na 128 mEq/L (low), K 5.4 mEq/L (high-normal), Glucose 58 mg/dL (low), Cr 1.4 mg/dL
• CBC: WBC 4,200 (eosinophils mildly elevated at 8%)
• Random cortisol: 2.1 mcg/dL (inappropriately low for acute stress; should be >18-20)
• ACTH: 8 pg/mL (low-normal) - suggests secondary/tertiary adrenal insufficiency
• Lactate: 3.2 mmol/L (elevated)

Diagnosis

Adrenal Crisis (Acute Adrenal Insufficiency) secondary to:

1. HPA axis suppression from chronic glucocorticoid therapy
2. Rapid glucocorticoid taper
3. Acute physiologic stress (gastroenteritis) without stress-dose steroids
4. Inability to absorb oral steroids due to vomiting

Pathophysiology

• Chronic exogenous glucocorticoids suppress the hypothalamic-pituitary-adrenal (HPA) axis
• Adrenal glands atrophy and cannot mount appropriate cortisol response to stress
• Rapid taper or acute illness without stress dosing precipitates crisis
• Secondary adrenal insufficiency (from exogenous steroids) differs from primary:
• ACTH is low (not elevated)
• Typically no hyperpigmentation
• Mineralocorticoid function often preserved (aldosterone regulated by renin-angiotensin, not ACTH)

Treatment Plan

IMMEDIATE RESUSCITATION:

1. IV Access and Fluids:

• Normal saline bolus 1-2 L over first hour
• D5NS if hypoglycemic
• Aggressive fluid resuscitation (patients are often severely volume depleted)

1. Stress-Dose Glucocorticoids:

• Hydrocortisone 100 mg IV bolus IMMEDIATELY
• Then hydrocortisone 50 mg IV every 6 hours (or 200 mg/24h continuous infusion)
• Hydrocortisone preferred because it has mineralocorticoid activity
• Alternative: Dexamethasone 4 mg IV if diagnostic testing pending (doesn't interfere with cortisol assay)

1. Identify and Treat Precipitant:

• IV antiemetics for nausea
• Supportive care for gastroenteritis
• Evaluate for infection (though fever may be absent in adrenal crisis)

1. Monitor:

• Continuous telemetry
• Serial electrolytes (Na, K, glucose)
• Hemodynamic monitoring

WHY HYDROCORTISONE?

• At stress doses (100+ mg/day), hydrocortisone provides sufficient mineralocorticoid effect
• No need for separate fludrocortisone during acute crisis
• If using dexamethasone (no mineralocorticoid activity), may need fludrocortisone

Glucocorticoid Equivalencies and Properties

Recovery and Transition

After Stabilization (24-48 hours):

1. Taper IV hydrocortisone as clinical status improves
2. Transition to oral hydrocortisone 20 mg AM / 10 mg PM (or prednisone equivalent)
3. Taper gradually back to maintenance dose over days to weeks
4. Do NOT rapidly return to previous low dose

STRESS DOSING EDUCATION (Critical):

Prevention and Patient Education

1. Medical alert bracelet: Must wear at all times
2. Emergency injection kit: Prescribe hydrocortisone 100 mg IM for home use
3. Sick day rules: Double/triple dose during illness; seek care if vomiting
4. Gradual tapers: Never stop chronic steroids abruptly
5. Inform all providers: Patient on chronic steroids needs stress dosing for procedures
6. HPA axis recovery: Takes 6-12 months after stopping chronic steroids; may need coverage during this period

Clinical Pearl

Any patient on glucocorticoids equivalent to prednisone >5 mg daily for >3 weeks has potential HPA axis suppression and is at risk for adrenal crisis if steroids are stopped abruptly or during physiologic stress. The triad of hypotension, hyponatremia, and hypoglycemia in a patient on chronic steroids should prompt immediate consideration of adrenal crisis - treat empirically with IV hydrocortisone before waiting for confirmatory labs. Chronic glucocorticoid-induced adrenal insufficiency is SECONDARY (pituitary suppression), so ACTH is low and hyperpigmentation is absent. At physiologic stress doses of hydrocortisone (>50 mg/day), additional mineralocorticoid is not needed. Patient education about sick day rules and medical alert identification is essential to prevent future crises.

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