Adrenal insufficiency may be misdiagnosed and inadequately treated in acute situations. A wide spectrum of presenting symptoms can delay recognition and lead to avoidable deterioration. Targeted strategies should be employed for patients with known diagnoses of adrenal failure, ensuring prompt triage and treatment. High-dose parental corticosteroids are the mainstay of treatment in hospital settings. Conversely, injudicious corticosteroid administration and a failure to consider differential diagnoses increases the risk of adverse events.
Two contrasting cases are presented. Case 1: a 21-year-old female with congenital adrenal hyperplasia due to 21-hydroxylase deficiency, presented to a rural Emergency Department with viral symptomology amid the COVID-19 pandemic. Emesis prevented her enteral sick-day action plan and a previous failure of the medical team to recognise the importance of her diagnosis, delayed her presentation for parenteral hydrocortisone. On this occasion, rapid recognition and treatment prevented the impending adrenal crisis, a catastrophic outcome especially in the context of an unknown COVID-19 status. Case 2: a 54-year-old male with known adrenal suppression secondary to long-term prednisolone therapy following renal transplant presented with signs of sepsis, three days after a cholecystectomy. Recurrent episodes of hypotension in the context of presumed ongoing sepsis triggered repeated and extended stress dose corticosteroid and vasopressor treatment, distracting from hypovolaemic circulatory failure. Eventually the heralding signs of melaena and accompanying fall in haemoglobin unveiled gastrointestinal haemorrhage. Eventual recognition triggered appropriate investigations and tailored tapering of corticosteroids by the Endocrinology team.
These cases demonstrate the importance of early recognition and consideration of differential diagnoses in acute presentations. Multi-level approaches are critical: patient empowerment to recognise symptoms and institute their sick-day plan; delivery of parenteral hydrocortisone during ambulance transfer; a system-based approach to identify at-risk patients; robust clinical assessment and appropriate dosing of steroid therapy. Early involvement of the Endocrinology team may reduce excess morbidity and mortality.