Vomiting, abdominal pain, and blood pressure of 84/52 mm Hg
A 37-year-old high school teacher presents with 3 days of vomiting, abdominal pain, and severe lightheadedness that began after eating packaged meals on a hiking trip. He takes levothyroxine for Hashimoto thyroiditis. He has received 2 L of intravenous 0.9% saline over 2 hours, but blood pressure remains 84/52 mm Hg with a pulse of 114/min. Examination shows dry mucous membranes, diffuse abdominal tenderness without guarding, and hyperpigmentation of the palmar creases and vermilion borders. Laboratory studies show serum sodium 127 mEq/L, potassium 5.7 mEq/L, bicarbonate 18 mEq/L, glucose 64 mg/dL, and an absolute eosinophil count of 850/uL (reference: <500/uL). Which of the following is the most appropriate next step in management?
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B
Explanation
Clinical Pearl:
In suspected acute adrenal crisis, emergent administration of intravenous hydrocortisone is life-saving and must never be delayed for diagnostic testing. High-dose hydrocortisone provides both potent glucocorticoid and sufficient mineralocorticoid activity, resolving refractory vascular collapse and electrolyte abnormalities.
Explanation:
This patient has acute adrenal crisis precipitated by a gastrointestinal illness in the setting of unrecognized primary adrenal insufficiency, as evidenced by refractory hypotension despite volume resuscitation, hyperpigmentation, hyponatremia, hyperkalemia, hypoglycemia, and peripheral eosinophilia. Current endocrine society guidance emphasizes that when acute adrenal crisis is suspected, high-dose intravenous hydrocortisone must be administered immediately without delay, as it restores vascular tone and provides sufficient mineralocorticoid activity to resolve the underlying shock. Infusion of 3% hypertonic saline is reserved for severe acute symptomatic hyponatremia with cerebral edema; in adrenal insufficiency, the hyponatremia is driven by hypovolemia and non-osmotic vasopressin release, which correct with volume resuscitation and glucocorticoid replacement, making hypertonic saline inappropriate and increasing the risk of osmotic demyelination. Performance of a cosyntropin stimulation test is the standard confirmatory evaluation in stable outpatients, but withholding steroid therapy to complete stimulation testing in an unstable patient in shock can prove fatal. Intravenous administration of regular insulin and dextrose is used for acute hyperkalemic emergencies in renal failure, but this patient is already hypoglycemic, and the hyperkalemia results from mineralocorticoid deficiency that will promptly resolve with hydrocortisone. Administration of oral fludrocortisone acetate is indicated for maintenance therapy in chronic primary adrenal insufficiency, but it has no role in acute crisis because oral absorption is unreliable during shock and high-dose intravenous hydrocortisone already provides maximal mineralocorticoid receptor stimulation.
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