Addisonian Crisis secondary to bilateral adrenal haemorrhage
Rahila S. Bhatti, Michael D. Flynn
East Kent University Hospitals NHS Trust, Canterbury, UK.
A 59 yr old Caucasian was admitted in May 2008 with a two week history of diarrhoea, vomiting, abdominal pain. Background history of diverticular disease with sigmoid colectomy in 2001. BP 85/58 mm Hg. He did not respond to fluid resuscitation, transferred to ITU for inotropic support, empirical steroids and antibiotics.
Investigations: WCC 21.8 x10‑9/L, CRP 325 mg/L, Cr 157umol/L, GFR 40 units, Lactate 3.5 mmol/L. CT Abdomen showed small bowel dilatation with a perforated terminal ileum on laporotomy requiring small bowel resection and ileostomy. On day 9 he had abdominal pain, clinically septic. A repeat CT Scan showed bilateral adrenal haemorrhage. He was in ITU for 2/52 requiring parenteral nutrition. Sodium130mmol/L, Potassium 5.2 mmol/L so a short synacthen test was done. Baseline plasma Cortisol 397 nmol/L and 30 min post tetracosactrin 482 nmol/L. No hydrocortisone was given. After one week, the serum cortisol was 428 nmol/L and he was discharged home by the surgeons.
In June2008 referred with acute renal failure. Sodium 122 mmol/L, Potassium 6.6 mmol/L. He was empirically started on hydrocortisone, required hemodialysis made excellent recovery and referred to endocrinologist.
In recovery period, a long synacthen test was done. Baseline Cortisol 345 noml/L with peak Cortisol 471 nmol/L 4 hrs post synacthen. Gradually weaned off the hydrocortisone other than during intercurrent illness. Plasma renin activity was normal.
Adrenal haemorrhage secondary to sepsis typically occurs in presence of meningococcemia (Waterhouse-Friederichsen Syndrome). Prevalence of adrenal insufficiency in septic shock varies but is estimated to occur in approximately half of patients with septic shock. Best test currently available for diagnosis is 1μg corticotrophin stimulation test. Recent evidence suggests that 1μg corticotrophin stimulation test is more sensitive than 250 μg corticotrophin test in establishing the diagnosis of secondary adrenal insufficiency.
Clinicians should be aware of risk of adrenal haemorrhage and subsequent loss of adrenal function.