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Adrenal crisis — ABIM Board MCQ

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ModerateEndocrinology/MetabolismAdrenal crisisABIM Board

A 52-year-old woman with known primary adrenal insufficiency develops persistent vomiting and abdominal pain during an influenza-like illness and has been unable to keep down her usual oral hydrocortisone. In the emergency department she is confused, with a blood pressure of 82/50 mm Hg and a heart rate of 118/min. Laboratory studies show a sodium level of 122 mEq/L, a potassium level of 5.8 mEq/L, and a glucose level of 52 mg/dL. Which of the following is the most appropriate initial management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Intravenous hydrocortisone plus 0.9% saline with dextrose

Explanation lettering: B = shown as A · C = shown as B · D = shown as C · E = shown as D · A = shown as E

This is adrenal crisis precipitated by intercurrent infection with failed oral glucocorticoid intake: hypotension, confusion, vomiting, hyponatremia, hyperkalemia, and hypoglycemia are characteristic. Treatment must begin immediately with parenteral stress-dose hydrocortisone (100 mg IV, then continued dosing) and rapid resuscitation with 0.9% saline; dextrose is added because her glucose is 52 mg/dL (choice B). Oral fludrocortisone (A) is inadequate—she cannot retain oral medication, and high-dose hydrocortisone supplies sufficient mineralocorticoid activity acutely. Fluid restriction (C) treats euvolemic hyponatremia such as SIADH and would worsen her hypovolemic shock; her hyponatremia corrects with saline and cortisol replacement. Insulin with dextrose (D) targets only the hyperkalemia, which resolves with volume and steroid replacement, and risks worsening hypoglycemia. Giving levothyroxine before glucocorticoids (E) is dangerous in any adrenal insufficiency because accelerating metabolism and cortisol clearance can deepen the crisis; steroids always come first.

Reference: NIDDK (NIH). Treatment for Adrenal Insufficiency & Addison's Disease — Adrenal crisis section. https://www.niddk.nih.gov/health-information/endocrine-diseases/adrenal-insufficiency-addisons-disease/treatment