Adrenal crisis !
Adrenal crisis is a sudden, life-threatening lack of cortisol that causes shock. It needs immediate steroids and fluids.
Updated 2026-11-01
Structures involved
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In embryology
In the clinical exam
Why it happens
- Shock: types, stages and the organs it damages
- Actions of cortisol
- Aldosterone: actions and control
- The HPA axis and its circadian rhythm
- Adrenal cortisol synthesis
- Adrenal cortex zones and medulla
What it is
An acute, life-threatening deficiency of cortisol (and in primary disease, aldosterone) presenting with hypotension or shock that responds to glucocorticoids. It can be the first presentation of adrenal insufficiency.
Who gets it
Each year a meaningful share of people with known adrenal insufficiency have a crisis, and some die from it. In Latin America, tuberculosis, infections such as paracoccidioidomycosis and histoplasmosis, and prolonged glucocorticoid use add to autoimmune causes.
Causes
- Known adrenal insufficiency with an illness, surgery or trauma without an increased glucocorticoid dose
- Abrupt withdrawal of long-term glucocorticoids
- Bilateral adrenal haemorrhage (sepsis, especially meningococcal; anticoagulation)
- Pituitary apoplexy or other sudden loss of ACTH
- Primary adrenal failure: autoimmune (Addison disease), tuberculosis and other infections
Risk factors
- Primary adrenal insufficiency
- Long-term or high-dose glucocorticoid therapy
- Vomiting or diarrhoea preventing oral steroid intake
- Lack of education on sick-day rules and emergency injection
Pathophysiology
Without cortisol, vascular tone and the response to catecholamines fail, and gluconeogenesis falls. In primary disease the lack of aldosterone adds salt wasting and potassium retention. The result is shock, hypoglycaemia, hyponatraemia and, in primary forms, hyperkalaemia.
Symptoms and signs
- Profound weakness and fatigue
- Nausea, vomiting and abdominal pain that may mimic an acute abdomen
- Dizziness, hypotension and shock
- Confusion or reduced consciousness
- Fever, and skin hyperpigmentation in chronic primary disease
Diagnosis
- Clinical
- Suspected in any unexplained shock, especially with known adrenal insufficiency, steroid use or hyperpigmentation. Treatment must not wait for results.
- Tests
- Serum cortisol and ACTH drawn before treatment (low cortisol confirms; high ACTH points to primary disease); sodium, potassium, glucose, creatinine. A cosyntropin stimulation test is done once the patient is stable.
- Imaging
- Abdominal CT to look for adrenal haemorrhage, tuberculosis or metastases; pituitary MRI when a central cause is suspected.
Differential diagnosis
- Septic shock
- Hypovolaemic shock
- Acute abdomen
- Diabetic ketoacidosis
- Myxoedema coma
Goal of treatment
Restore cortisol and circulating volume at once, correct glucose and electrolytes, treat the trigger and prevent new crises.
Treatment
- Acute
- Immediate parenteral hydrocortisone, without waiting for laboratory results.
- Acute
- Rapid intravenous isotonic saline with dextrose to restore volume and correct hypoglycaemia.
- Follow-up
- Blood pressure, fluid balance, glucose, sodium and potassium; nursing focus on fast venous access and watching for over-rapid sodium correction.
- Medical
- Tapering to oral maintenance glucocorticoid, with mineralocorticoid replacement in primary disease, and treatment of the trigger (infection, tuberculosis).
- Lifestyle
- Patient education: sick-day rules for increasing steroids, an emergency injection kit and a medical alert card or bracelet.
Complications
- Refractory shock and death
- Hypoglycaemic brain injury
- Cardiac arrhythmias from hyperkalaemia
- Osmotic demyelination if hyponatraemia is corrected too fast
Prognosis
With prompt hydrocortisone and fluids, recovery is usually rapid. Delay is the main cause of death; education reduces recurrences.
Prevention
- Sick-day rules and stress dosing for illness, surgery and procedures
- Gradual tapering of long-term glucocorticoids
- Emergency card and self-injection training
Test yourself
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What is the first treatment in suspected adrenal crisis?
Immediate parenteral hydrocortisone plus intravenous saline, without waiting for test results.
Which electrolyte pattern suggests primary adrenal insufficiency?
Hyponatraemia with hyperkalaemia, from loss of aldosterone; hypoglycaemia may also be present.
What is the most common trigger of adrenal crisis in a patient on chronic steroids?
An acute illness (often gastrointestinal infection) or stopping steroids without increasing or tapering the dose.
Which infection classically causes bilateral adrenal haemorrhage?
Meningococcal sepsis (Waterhouse-Friderichsen syndrome).
Related conditions
- Adrenal insufficiency
- Sepsis and septic shock
- Hypovolaemic shock
- Hypoglycaemia (including insulin-induced)
- Pituitary adenoma
- Tuberculosis
- Myxoedema coma
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Acute adrenal crisis (MedlinePlus Medical Encyclopedia (U.S. National Library of Medicine), 2025).
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Representative model, for educational purposes only.
