Adrenal Crisis: Symptoms, Types, Causes and Treatment

Adrenal crisis is a medical emergency that can threaten the lives of people living with adrenal insufficiency. Despite advances in endocrinology and the availability of hormone replacement therapy, adrenal crises still occur frequently and are often underestimated in both their incidence and severity. Early recognition and prompt treatment are essential to prevent life-threatening complications. In this article, we explore adrenal crisis in depth—its symptoms, types, causes, and best-practice treatments—to empower patients, caregivers, and clinicians with critical, evidence-based knowledge.

Symptoms of Adrenal Crisis

Adrenal crisis often strikes suddenly, but its warning signs can be subtle or mistaken for other conditions. Recognizing these symptoms quickly is vital for effective intervention and survival. While adrenal crisis symptoms are broad and sometimes nonspecific, certain patterns are strongly suggestive of this condition.

Symptom	Description	Frequency/Severity	Source(s)
Hypotension	Low blood pressure, may cause collapse	Common, can be severe	1 3 5 15
Nausea/Vomiting	Gastrointestinal upset, may be intense	Very common	1 3 4 5 11
Fever	Elevated body temperature	Often present	1 5 11
Weakness	Profound fatigue, malaise	Nearly universal	2 3 4
Confusion/Altered Sensorium	Mental status changes	May progress to coma	4 5 11
Abdominal Pain	Cramping or diffuse pain	Frequently reported	5 11
Hyperpigmentation	Darkening of skin (chronic AI)	Seen in chronic cases	2
Hyponatremia/Hyperkalemia	Low sodium/high potassium	Especially in primary AI	2 6
Shock	Circulatory collapse, can be fatal	Medical emergency	1 5 11

Table 1: Key Symptoms

Recognizing the Clinical Picture

The hallmark of adrenal crisis is hypotension (low blood pressure), which can quickly deteriorate into shock and circulatory collapse if untreated. Patients often experience severe nausea, vomiting, and abdominal pain, making adrenal crisis easy to mistake for gastrointestinal illnesses—a leading cause of misdiagnosis 5 11.

Fever is also a common feature, especially when infection is the trigger. Profound weakness and malaise, sometimes described as a feeling of being "utterly unwell," are nearly universal 2 3. As the crisis progresses, confusion, disorientation, or even coma can develop, signaling brain dysfunction due to low blood pressure and metabolic imbalances 4 5 11.

Electrolyte disturbances—specifically hyponatremia (low sodium) and hyperkalemia (high potassium)—are seen mainly in primary adrenal insufficiency, reflecting the loss of aldosterone, an adrenal hormone crucial for salt balance 2 6. Hyperpigmentation, while not a crisis symptom per se, is a sign of chronic primary adrenal insufficiency and may help with diagnosis 2.

Shock, defined as life-threatening circulatory failure, is the endpoint of untreated adrenal crisis and necessitates immediate emergency intervention 1 5 11.

Types of Adrenal Crisis

Adrenal crisis is not a one-size-fits-all event. The underlying cause of adrenal insufficiency, and the context in which crisis occurs, determine its features and risk profile. Understanding these types is key to prompt recognition and tailored management.

Type	Underlying Cause	Unique Features / Risks	Source(s)
Primary	Adrenal gland destruction	More severe electrolyte imbalance	2 5 6 8
Secondary	Pituitary or hypothalamic failure	Fewer electrolyte issues	5 6 7
Tertiary (Iatrogenic)	Chronic steroid therapy	Often subtle onset, at-risk pop.	6 7
Acute (Sudden)	Hemorrhage, trauma, surgery	Rapid symptom development	3 6

Table 2: Types of Adrenal Crisis

Primary vs. Secondary vs. Tertiary Crisis

Primary adrenal crisis results from direct adrenal gland damage—most commonly autoimmune destruction (Addison’s disease), but also from infection, metastasis, or surgical removal. Because both cortisol and aldosterone are deficient, these patients are at higher risk for dangerous electrolyte disturbances (hyponatremia, hyperkalemia) and are more prone to crisis 2 5 6 8.

Secondary adrenal crisis stems from pituitary or hypothalamic disease, which impairs the production of ACTH (the hormone signaling the adrenals to make cortisol). Since aldosterone production is largely preserved, these crises often lack the severe salt wasting seen in primary types, but still cause life-threatening cortisol deficiency 5 6.

Tertiary (iatrogenic) adrenal crisis occurs when long-term use of exogenous steroids (e.g., prednisone for autoimmune disease or asthma) suppresses the body’s own stress hormone system. Stopping steroids abruptly or failing to increase doses during illness or surgery can precipitate crisis. This is now the most common form of adrenal insufficiency in adults, yet frequently goes unrecognized 6 7.

Acute vs. Chronic Presentation

Acute adrenal crisis may develop suddenly—even in hours—especially after hemorrhage into the adrenal glands, trauma, or during major stress in a person with undiagnosed or untreated adrenal insufficiency 3 6. In contrast, chronic adrenal insufficiency can simmer for months or years with subtle symptoms before crisis is unmasked by an infection or other stressor 2.

Causes of Adrenal Crisis

Understanding what triggers adrenal crisis is crucial for prevention. While the underlying insufficiency sets the stage, certain factors increase the risk of crisis, many of which are preventable or manageable with vigilance and education.

Cause/Trigger	Mechanism	Notes/Prevalence	Source(s)
Infections	Increased demand, impaired response	Most common trigger	1 8 9 10 11
Gastrointestinal illness	Vomiting/diarrhea cause losses	Dehydration worsens crisis	8 10 11
Surgery/Trauma	Acute stress, increased cortisol need	Requires "stress dosing"	1 8 13
Abrupt steroid withdrawal	Suppressed adrenal axis	Iatrogenic crisis	6 7
Emotional/Physical stress	Increased hormone demand	Can precipitate crisis	8 9 10
Medication interference	E.g., antifungals (fluconazole)	Can inhibit cortisol synthesis	4
Heat/Dehydration	Fluid losses, increased demand	Less common, but significant	8 9 10
Unknown (idiopathic)	No identifiable trigger	Up to 12% of cases	8 9

Table 3: Main Causes of Adrenal Crisis

Infections and Other Stressors

Infections—especially gastrointestinal illnesses with vomiting and diarrhea—are the number one precipitant of adrenal crisis. These illnesses both increase the body’s need for cortisol and cause fluid/electrolyte losses, rapidly overwhelming a person with adrenal insufficiency 1 8 9 10 11. Fever further raises the body's requirement for stress hormones.

Surgery, trauma, and severe pain are also major triggers, as the body’s demand for cortisol can spike several-fold. Without adequate "stress dosing" of hydrocortisone, an adrenal crisis can ensue 1 8 13.

Medication-Related and Iatrogenic Causes

Iatrogenic (medication-induced) adrenal crisis is increasingly recognized. Long-term steroid therapy for conditions like asthma, rheumatoid arthritis, or after organ transplantation suppresses the body's own adrenal axis. Sudden withdrawal or failure to increase steroids during illness, surgery, or other stress can precipitate crisis 6 7. Certain medications—such as antifungals (e.g., fluconazole)—can also interfere with steroid metabolism, leading to acute insufficiency 4.

Emotional Stress, Heat, and Idiopathic Cases

Emotional and physical stress (such as major psychological distress, strenuous exercise, or extreme heat) can also precipitate crisis, though less frequently than infection or surgery 8 9 10. In some cases, no clear trigger is found—emphasizing the unpredictable nature of adrenal crisis and the need for ongoing vigilance 8 9.

Treatment of Adrenal Crisis

Prompt, decisive treatment is the cornerstone of surviving adrenal crisis. Delays can be fatal, but effective therapy—primarily intravenous hydrocortisone and fluid resuscitation—usually produces rapid improvement. Prevention, patient education, and emergency preparedness are equally vital.

Treatment	Description	Key Points	Source(s)
IV Hydrocortisone	100mg bolus, then continuous infusion	Mainstay, rapid effect	1 6 13 14
IV Fluids (Saline)	0.9% saline, 1L in first hour	Corrects shock/dehydration	1 6
Treat Underlying Cause	Antibiotics, etc.	Address infection, surgery	11 14
Monitor Electrolytes	Sodium, potassium, glucose	Adjust fluids/meds as needed	2 6 15
Prevention	Stress dosing, education, kits	Emergency card, self-injection	1 11 14

Table 4: Main Treatments and Strategies

Emergency Medical Management

Hydrocortisone replacement is the absolute priority. The recommended regimen is an immediate IV bolus of 100 mg hydrocortisone, followed by 200 mg over 24 hours as a continuous infusion or divided boluses 1 6 13 14. This mimics the high cortisol levels seen in major stress and is proven to restore blood pressure and reverse shock quickly.

Fluid resuscitation with 0.9% saline (1L within the first hour) corrects dehydration, supports blood pressure, and helps reverse electrolyte imbalances 1 6.

Addressing Triggers and Ongoing Monitoring

Treat any underlying infection, injury, or surgical complication that may have triggered the crisis—typically with antibiotics, surgery, or other appropriate interventions 11 14.

Continuous monitoring of electrolytes (sodium, potassium), blood glucose, and vital signs is essential, as adjustments to fluids and medications may be needed to prevent complications 2 6 15.

Prevention and Patient Empowerment

Prevention hinges on patient and provider education:

• Patients with adrenal insufficiency must know "sick day rules"—to double or triple their steroid dose during illness or stress, and to use emergency injectable hydrocortisone if unable to tolerate oral medications or during severe illness 1 11 14.
• Every patient should carry an emergency card and have a readily accessible emergency injection kit for hydrocortisone self-administration 1 11 14.
• Repeated, practical training on when and how to use emergency medications is crucial, as studies show education alone is not always sufficient 1 10 11.
• Development and use of easier-to-administer hydrocortisone pens may further lower barriers to effective self-treatment 1.

Ongoing research is exploring improved glucocorticoid formulations and delivery methods to better mimic natural cortisol rhythms and reduce the incidence of crisis 12 13 15.

Conclusion

Adrenal crisis remains a major, potentially fatal complication for people with adrenal insufficiency, but with awareness and preparation, many crises can be prevented or effectively treated. Key takeaways include:

• Symptoms are often nonspecific but include hypotension, severe weakness, gastrointestinal upset, and altered mental status.
• Types of adrenal crisis reflect the underlying cause—primary, secondary, tertiary (iatrogenic), or acute onset—each with unique risks and features.
• Causes are most often infections, especially gastrointestinal illnesses, but also include surgery, trauma, medication effects, and emotional or physical stress.
• Treatment requires immediate IV hydrocortisone and fluids, with a strong emphasis on prevention via patient education, emergency kits, and stress dosing protocols.

Empowering patients and clinicians through education, readiness, and rapid response is the best defense against this still-deadly endocrine emergency.