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Adrenal crisis in critical illness — RCPSC IM MCQ

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HardCritical CareAdrenal crisis in critical illnessRCPSC IM

A patient taking prednisone 20 mg daily for several months stops it abruptly during pneumonia. He develops refractory hypotension, hyponatremia and hypoglycemia. Which mechanism best explains the deterioration?

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Correct answer: C — Iatrogenic HPA-axis suppression causing adrenal crisis

The best answer is “Iatrogenic HPA-axis suppression causing adrenal crisis”. Prolonged exogenous glucocorticoid therapy suppresses the hypothalamic-pituitary-adrenal axis, and abrupt withdrawal during severe illness can precipitate adrenal crisis. The competing endocrine diagnoses do not fit the medication history and combined shock, hyponatremia and hypoglycemia. Prolonged exogenous glucocorticoid exposure suppresses corticotropin-releasing hormone and ACTH; abrupt withdrawal during infection therefore prevents an adequate endogenous cortisol surge.

Reference: Emergency Care BC, adrenal crisis clinical summary: https://emergencycarebc.ca/wp-content/uploads/2022/06/Adrenal-Crisis-sept2020-v2-Summary.pdf