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Adrenal emergency steroid card. Permission to reprint granted by the Addisons Disease Self-Help Group, addisonsdisease.org.uk
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Adrenal crisis is an acute life-threatening emergency contributing to the excess mortality that is reported in patients with adrenal insufficiency. The incidence of adrenal crisis is estimated to be 8 per 100 patient years in patients with adrenal insufficiency. Patients with adrenal crisis present systemically unwell with nonspecific signs and sym...
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Background
Coronavirus disease 2019 is an emerging respiratory disease caused by a novel coronavirus effect on 10-20% of total healthcare workers and was first detected in December 2019 in Wuhan, China. This study was designed to assess effect of COVID-19 stressors on healthcare workers’ performance and attitude. A descriptive cross sectional resea...
Citations
... Недіагностована надниркова недостатність може бути небезпечною для життя. Тому дослідження функції НЗ у хворих на гемодіалізі, особливо після терапії глюкокортикоїдами або у пацієнтів з хронічною гіпотензією, є звичайною процедурою [43]. ...
In the previous article, we presented the results of literature review showing the changes in hormone concentrations (parathyroid hormone, insulin, growth factor, prolactin) in patients with chronic renal failure (CRF) at the pre-dialysis and dialysis stages, described pathological relationships between renal failure and serum hormones concentrations, as well as changes in their biological effects. In this article, that continues the general topic, we provide the results of literature review that shows changes in serum concentrations of thyroid, adrenal, sex hormones and the features of the functioning of hypothalamus-pituitary-peripheral glands axis in patients with CRF. The presence of close pathogenic interactions of renal functional condition with hormonal activity of the thyroid gland was evaluated, as well as the ability of thyroid gland to influence the CRF progression both during pre-dialysis and dialysis stages of CRF. Most patients with CRF have low serum triiodothyronine and thyroxine levels. It means that CRF is a pathological condition associated with thyroid hypofunction that progressively worsening as glomerular filtration rate decreases. For patients receiving dialysis treatment, hypothyroidism is associated with higher mortality. Secondary adrenal insufficiency is usually progresses in patients on renal replacement therapy. Non-diagnosed chronic adrenal failure may be life-threating that’s why the analysis of adrenal function is especially actual for patients on both pre-dialysis and dialysis stages of CRF. Secondary adrenal insufficiency caused by long-lasting treatment with corticoids is a diagnostic problem for patients on dialysis treatment, because many nephrological diseases are treated by corticoids, and immunosuppressive therapy protocols used after the kidney transplantation are usually include prednisone. As the endocrine dysfunction progresses in patients with CRF, sexual dysfunction develops due to sex hormone imbalance. Abnormal androgen concentration is a typical finding in CRF. A negative correlation was found between endogenic testosterone concentration and CRF stages I–V that indicated an abnormal profile of male sex hormones. There are gender-specific features of the development and progression of clinical symptoms of hormonal imbalance. The number of experimental studies show that continuous estradiol treatment may prevent the development of glomerulosclerosis. The results of clinical trials concluded that lower CRF progression and the lower incidence of CRF observed in young females compared to males, as well as the absence of gender protection in post-menopausal period, shows the important role of female sex hormones.
... At present, regular ambulances in Stockholm do not carry magnesium sulphate; only RRVs can provide this medication and the treatments that patients with severe eclampsia or preeclampsia need. Similarly, for patients with adrenal insufficiency, a crisis can be life-threatening [35] and requires prompt treatment with hydrocortisone [36]. Again, only RRVs currently provide this medication and treatment. ...
Background
The aim of this study was to determine when and how rapid response vehicles (RRVs) make a difference in prehospital care by investigating the number and kinds of RRV assignment dispatches and the prehospital characteristics and interventions involved.
Methods
This retrospective cohort study was based on data from a quality assurance system where all assignments are registered. RRV staff register every assignment directly at the site, using a smartphone, tablet, or computer. There is no mandatory information requirement or time limit for registration. The study includes data for all RRVs operating in Region Stockholm, three during daytime hours and one at night – from January 1, 2021 to December 31, 2021.
Results
In 2021, RRVs in Stockholm were dispatched on 11,283 occasions, of which 3,571 (31.6%) resulted in stand-downs. In general, stand-downs were less common for older patients. The most common dispatch category was blunt trauma (1,584 or 14.0%), which accounted for the highest frequency of stand-downs (676 or 6.0%). The second most common category was cardiac arrest (1,086 or 9.6%), followed by shortness of breath (691 or 6.1%), medical not specified (N/S) (596 or 5.3%), and seizures (572 or 5.1%).
Conclusion
The study findings confirm that RRVs provide valuable assistance to the ambulance service in Stockholm, especially for cardiac arrest and trauma patients. In particular, RRV personnel have more advanced medical knowledge and can administer medications and perform interventions that the regular ambulance service cannot provide.
... It has been associated with several entities, notably infections in the context of Waterhouse-Friderichsen syndrome. 1 A rare etiology is antiphospholipid syndrome (APS). There are cases of BAH in patients taking anticoagulants because of previous thrombotic events or using anticoagulation as prophylaxis in the postoperative period who are later diagnosed with APS. ...
A 62-year-old man was admitted to the emergency department with hypotension and altered consciousness. On physical examination, he had hyperpigmentation of the skin and mucous membranes. Admission tests revealed hypoglycemia, hyponatremia, and hyperkalemia. Fluid resuscitation was initiated with no improvement in blood pressure. Because adrenal crisis was suspected, blood samples for cortisol and adrenocorticotropic hormone were collected before commencing hydrocortisone, after which blood pressure improved and electrolyte disturbances disappeared. The tests revealed decreased serum cortisol and an increase in adrenocorticotropic hormone. A magnetic resonance imaging scan of the abdomen revealed evidence of bilateral adrenal hemorrhage. Positive antiphospholipid antibodies were detected during the investigations. This case underscores the importance of prompt evaluation of clinical signs and symptoms that may indicate adrenal crisis.
... Adrenal crisis is most often precipitated by infections. Other factors include hyperthyroidism, physical stress from surgery or trauma, inadvertent discontinuation of glucocorticoid medications, intense physical exercise, and psychological stress [17]. Early diagnosis, rehydration, and steroid replacement form the cornerstones of management, without which catastrophic outcomes including death can result. ...
The diagnosis of adrenal insufficiency (AI) requires a high index of suspicion, detailed clinical assessment including detailed drug history, and appropriate laboratory evaluation. The clinical characteristics of adrenal insufficiency vary according to the cause, and the presentation may be myriad, e.g. insidious onset to a catastrophic adrenal crisis presenting with circulatory shock and coma. Secondary adrenal insufficiency (SAI) often presents with only glucocorticoid deficiency because aldosterone production, which is controlled by the renin angiotensin system, is usually intact, and rarely presents with an adrenal crisis. Measurements of the basal serum cortisol at 8 am (<140 nmol/L or 5 mcg/dL) coupled with adrenocorticotrophin (ACTH) remain the initial tests of choice. The cosyntropin stimulation (short synacthen) test is used for the confirmation of the diagnosis. Newer highly specific cortisol assays have reduced the cut-off points for cortisol in the diagnosis of AI. The salivary cortisol test is increasingly being used in conditions associated with abnormal cortisol binding globulin (CBG) levels such as pregnancy. Children and infants require lower doses of cosyntropin for testing. 21-hydoxylase antibodies are routinely evaluated to rule out autoimmunity, the absence of which would require secondary causes of adrenal insufficiency to be ruled out. Testing the hypothalamic–pituitary–adrenal (HPA) axis, imaging, and ruling out systemic causes are necessary for the diagnosis of AI. Cancer treatment with immune checkpoint inhibitors (ICI) is an emerging cause of both primary AI and SAI and requires close follow up. Several antibodies are being implicated, but more clarity is required. We update the diagnostic evaluation of AI in this evidence-based review.
... (4,5) Although postoperative fever after major surgical procedures is a relatively common event that occurs in between Page 4/13 surgery. The overall incidence of complications associated with laparoscopic adrenalectomy was previously reported to be 9.5% (range 2. [9][10][11][12][13][14][15][16][17][18][19][20], with the most common postoperative complication being bleeding (21.5% of all cases), followed by wound complications (13%). The exact incidence of postoperative fever has not yet been reported, while other complications, including fever, occur at an incidence of approximately 9.5% and include thromboembolism, neurological abnormalities, anemia, neutropenia, nausea, headache, shoulder tip pain, and subcutaneous and mediastinal emphysema (2). ...
Background: Laparoscopic adrenalectomy is widely performed for a number of hormone-producing tumors and postoperative management depends on the hormones produced. In the present study, we conducted a retrospective analysis to clarify the risk factors for postoperative complications, particularly postoperative fever after laparoscopic adrenalectomy.
Methods: We analyzed 406 patients who underwent laparoscopic adrenalectomy at our hospital between 2003 and 2019. Postoperative fever was defined as a fever of 38°C or higher within 72 hours after surgery. We investigated the risk factors for postoperative fever after laparoscopic adrenalectomy.
Results: There were 188 males (46%) and 218 females (54%) with a median age of 52 years. Among these patients, tumor pathologies included 188 primary aldosteronism (46%), 75 Cushing syndrome (18%), and 80 pheochromocytoma (20%). Postoperative fever developed in 124 of all patients (31%), 30% of those with primary aldosteronism, 53% of those with pheochromocytoma, and 8% of those with Cushing syndrome. A multivariate logistic regression analysis identified pheochromocytoma and non-Cushing syndrome as independent predictors of postoperative fever. Postoperative fever was observed in 42 out of 80 cases of pheochromocytoma (53%), which was significantly higher than in cases of non-pheochromocytoma (82/326, 25%, p<0.01). In contrast, postoperative fever developed in 6 out of 75 cases of Cushing syndrome (8%), which was significantly lower than in cases of non-Cushing syndrome (118/331, 35.6%, p<0.01).
Conclusion: Since postoperative fever after laparoscopic adrenalectomy is markedly affected by the hormone produced by pheochromocytoma and Cushing syndrome, it is important to carefully consider the need for treatment.
... Further evaluation is needed in terms of surgical approach.Only 8% of patients with Cushing syndrome developed postoperative fever in the present study. Although complex local variations in cortisol levels and the mechanisms of homeostasis in the body have not yet been fully elucidated, they are considered to have important functions in the hypothalamus and pituitary gland, such as the control of in ammation and maintenance of body temperature.(10) ...
Purpose: Laparoscopic adrenalectomy is widely performed for a number of hormone-producing tumors and postoperative management depends on the hormones produced. In the present study, we conducted a retrospective analysis to clarify the risk factors for postoperative complications, particularly postoperative fever after laparoscopic adrenalectomy.
Methods: We analyzed 406 patients who underwent laparoscopic adrenalectomy at our hospital between 2003 and 2019. Postoperative fever was defined as a fever of 38°C or higher within 72 hours after surgery. We investigated the risk factors for postoperative fever after laparoscopic adrenalectomy.
Results: There were 188 males (46%) and 218 females (54%) with a median age of 52 years. Among these patients, tumor pathologies included 188 primary aldosteronism (46%), 75 Cushing syndrome (18%), and 80 pheochromocytoma (20%). Postoperative fever developed in 124 of all patients (31%), 30% of those with primary aldosteronism, 53% of those with pheochromocytoma, and 8% of those with Cushing syndrome. A multivariate logistic regression analysis identified pheochromocytoma and non-Cushing syndrome as independent predictors of postoperative fever. Postoperative fever was observed in 42 out of 80 cases of pheochromocytoma (53%), which was significantly higher than in cases of non-pheochromocytoma (82/326, 25%, p<0.01). In contrast, postoperative fever developed in 6 out of 75 cases of Cushing syndrome (8%), which was significantly lower than in cases of non-Cushing syndrome (118/331, 35.6%, p<0.01).
Conclusion: Since postoperative fever after laparoscopic adrenalectomy is markedly affected by the hormone produced by pheochromocytoma and Cushing syndrome, it is important to carefully consider the need for treatment.
... Signs and symptoms of an Addisonian crisis[8] ...
Background
We report a novel presentation of deficit in anterior pituitary function with variable immune deficiency (DAVID) syndrome in a healthy young girl presenting in Addisonian crisis with raised intracranial pressure. Nearly all cases of DAVID syndrome described in the literature have presented with recurrent infections and variable immunodeficiency. Pseudotumour cerebri has not been reported in DAVID syndrome to date.
Case presentation
A four-year-old girl represented to hospital with vomiting, confusion and diplopia after ten days of tiredness, neck and abdominal pain, and headache. Her cranial nerve examination demonstrated a right abducens nerve palsy and papilloedema, and she was found to have ketotic hypoglycaemia and hypocortisolaemia secondary to adrenocorticotrophic hormone (ACTH) deficiency. Her neuroimaging was consistent with pseudotumour cerebri, and her lumbar puncture opening pressure confirmed raised intracranial pressure (30–40 cmH 2 O). Cerebrospinal fluid analysis was normal. The patient’s symptoms improved with hydrocortisone replacement and acetazolamide, but the raised intracranial pressure recurred after acetazolamide was discontinued. She was subsequently found to have panhypogammaglobulinaemia, and DAVID syndrome was diagnosed. Genetic testing demonstrated a truncating mutation in the NFKB2 gene c.2557C > T, p .(Arg853*).
Conclusions
This case demonstrates pseudotumour cerebri as a novel neurological presentation of DAVID syndrome, highlights the rare association between adrenal insufficiency and intracranial hypertension, and shows the challenges in diagnosing isolated ACTH deficiency. We emphasise that cortisol should be checked in pre-pubertal children with pseudotumour cerebri and a diagnosis of DAVID syndrome considered in those presenting with low cortisol and neurological symptoms.
... The most common cause of PAI is autoimmune adrenalitis, accounting for 68% to 94% of cases. 1,2 Adrenal crisis is a life-threatening complication of AI, with a prevalence of about 5.2-8.3 per 100 patient-years, and mortality of 0.5 per 100 patient-years. 2,3 It can be triggered by an infection, trauma, or other acute stressor and is characterized by hypotension, fever, gastrointestinal symptoms, somnolence, hyponatremia, and hyperkalemia. ...
... 1,2 Adrenal crisis is a life-threatening complication of AI, with a prevalence of about 5.2-8.3 per 100 patient-years, and mortality of 0.5 per 100 patient-years. 2,3 It can be triggered by an infection, trauma, or other acute stressor and is characterized by hypotension, fever, gastrointestinal symptoms, somnolence, hyponatremia, and hyperkalemia. 1,2 If adrenal crisis is suspected, urgent treatment with parenteral hydrocortisone is required. ...
... 2,3 It can be triggered by an infection, trauma, or other acute stressor and is characterized by hypotension, fever, gastrointestinal symptoms, somnolence, hyponatremia, and hyperkalemia. 1,2 If adrenal crisis is suspected, urgent treatment with parenteral hydrocortisone is required. 2,4 Patients with PAI are at increased risk for decreased bone mineral density and hip fractures. ...
Background
/Objective: Adrenal crisis is a medical emergency and an acute complication of adrenal insufficiency. It can be triggered by stressors such as infection, dehydration, trauma, or surgery.
Case Report
We present a case of a 70-year-old woman with a history of Addison’s disease, who presented in adrenal crisis within 24 hours after receiving her first infusion of zoledronic acid. No trigger was identified after extensive evaluation, making infusion with zoledronic acid the most likely cause of adrenal crisis.
Discussion
Adverse reactions to medications can potentially trigger adrenal crisis. The present case report demonstrates that intravenous bisphosphonates can cause an acute phase reaction that may lead to adrenal crisis. Given the increased risk of osteoporosis in patients with adrenal insufficiency there is an increased likelihood of prescription of intravenous bisphosphonates in this patient population.
Conclusion
Patients with adrenal insufficiency undergoing infusion with zoledronic acid may require an increased dose of glucocorticoid prior to infusion and may need to undergo monitoring post infusion for possible adrenal crisis.
... Clinical features and routine laboratory findings in adrenal crisis in patients with glucocorticoid induced adrenal insufficiency (GC-AI)9 ...
... If the concentrations are very low, the diagnosis is established. In the setting of primary and secondary adrenal insufficiency, random cortisol levels alone are usually not adequate in providing a diagnosis because of the wide fluctuations due to the pulsatile nature and diurnal variation of secretion(6) Cooper et al. stated that adrenal insufficiency appears to be likely when a random cortisol measurement is below 15 μg/dl during acute severe illness (8). If the concentrations are intermediate, an ACTH stimulation test should be performed. ...
This is a case report of 65 year old male who presented with necrotising fasciitis of leg lower limb who underwent emergency fasciotomy and debridement and was discharge with uneventful postoperative period , only to return to the casualty in respiratory distress and in shock. With further evaluation in ICU, patient was found to be in acute adrenal crisis and on further detailed history it was found that patient was on steroids for chronic joint pain and he had stopped abruptly which had lead to the current scenario Conclusion:Surgeons treating acute conditions should be aware of the HPA axis suppression and its appropriate therapy at emergency and further requirement of evaluation and referral for the best patient care
