Adrenal insufficiency and adrenal crisis — branching viva

Branching viva from the primary-versus-secondary split, through the pigmented losing-weight adolescent with autoimmune Addison disease, the steroid-withdrawn child who collapses with an infection, the cortisol-ACTH-renin work-up, and the empiric hydrocortisone-first resuscitation with a lifelong stress-dose plan.

branching clinical structured oral2 min readVerification in progress

Prompt

You are the paediatric registrar in the emergency department. Three children arrive in succession: a pigmented adolescent in shock with a low sodium and a high potassium, a pale asthmatic boy who stopped his oral steroid six weeks ago and is now drowsy and hypoglycaemic, and a known adrenal child on hydrocortisone who is vomiting with a fever. The examiner releases information in stages.

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]

Paediatrics Fellowship Pro

You have read the opening of this viva. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References5Show ledger

[1]Bornstein SR; Allolio B; Arlt W; et al Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2016.PMID 26760044
[3]Shulman DI; Palmert MR; Kemp SF; Lawson Wilkins Drug and Therapeutics Committee Adrenal insufficiency: still a cause of morbidity and death in childhood. Pediatrics, 2007.PMID 17242136
[4]Rushworth RL; Torpy DJ; Falhammar H Adrenal Crisis. N Engl J Med, 2019.PMID 31461595
[6]Beuschlein F; Dekkers OM; Arlt W; et al European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab, 2024.PMID 38724043
[7]Dong VH; Husebye ES; Tomlinson JW; et al Clinical features, investigation, and management of Addison's disease. Lancet Diabetes Endocrinol, 2026.PMID 41587556