Endocrinology: Adrenal Crisis

Question 1

Outline the pathophysiology of an Adrenal Crisis

Answer 1

Primary = fail to release adequate amounts (ADDISONS)

Secondary = exogenous steroids suppress HPA

zona glomerulosa = mineralocorticoids (aldosterone)

zona fasiculata = glucocorticoids (cortisol)

zona reticularis = androgens (dehydroepiandrosterone)

low Na = low aldosterone that would normally promote Na reabsorption

high K = reduced renal perfusion, water retention which dilutes extracellular fluid, cells to leak K

low BP = low Na, low intravascular vol

high urea = circulatory collapse impairs urinary excretion of waste products

Question 2

Outline the aetiology of an Adrenal Crisis

Answer 2

Autoimmune = isolated or polyglandular

Infection = TB, fungal, AIDS

Infiltration = amyloid, haemochromatosis

Malignancy = lung, breast, kidney

Genetic = congenital adrenal hyperplasia (CAH), adreno-leukodystrophy

Vascular = haemorrhage, infarction

Iatrogenic = adrenalectomy, drugs

Withdrawal form exogenous steroids = secondary adrenocortical insufficiency

Question 3

What are the signs and symptoms of an Adrenal Crisis?

Answer 3

Syncope

Hypotension

Dehydration

Pigmentation = decreased cortisol means increased POMC and MSH = hyperpigmentation

Coma

Nausea, vomiting, abdo pain

Question 4

How would you investigate an Adrenal Crisis?

Answer 4

Bloods = low Na, high K, low cortisol (<20mcg/dL), glucose (low)

Blood cultures

ACTH = determine baseline cortisol, give ACTH, then draw cortisol at 30/60mins

CXR = TB, malignant disease

Abdo CT = visualise adrenal glands

Question 5

How would you manage an Adrenal Crisis?

Answer 5

Rapid rehydration with fluids

IV hydrocortisone

Correction of hypoglycaemia

Search for precipitating cause

Question 6

What is the role of cortisol?

Answer 6

Gluconeogenesis, proteolysis, FA,= mobilisation, increased insulin.

Question 7

What is the role of aldosterone?

Answer 7

Promote Na reabsorption, K/H secretion via increased Na/k Pump.

Question 8

What are the possible complication of an adrenal crisis?

Answer 8

Death

Seizures

Arrhythmias

Coma

Question 9

What can long term steroid use result in?

Answer 9

Pathological fractures of the spine - osteoporosis

Infections

Infertility

Question 10

What evidence can patients keep to let people know they are on longterm steroids?

Answer 10

MedicAlert® identification

Steroid treatment card

Emergency crisis letter