Adrenal insufficiency and adrenal crisis — branching viva

Branch 1 — The pigmented adolescent in shock

The candidate is expected to recognise primary adrenal insufficiency from the hyperpigmentation, the postural hypotension, the weight loss and the hyponatraemia with hyperkalaemia, and to lead with empiric hydrocortisone and fluids before any confirmatory test. The examiner probes the cortisol-ACTH-renin interpretation and the dose of parenteral hydrocortisone. ^[4]

Key teaching points the candidate must land: the high ACTH and high renin with low aldosterone localise the break to the adrenal cortex; the hyperpigmentation is driven by ACTH-driven melanocyte-stimulating POMC fragments; the dose is 50 to 100 mg of intravenous hydrocortisone for an adolescent, then 50 to 100 mg per square metre per 24 hours; and sepsis is covered in parallel because it coexists and is indistinguishable. ^[1]