Phys · endocrine
Adrenal Disorders
Also known as adrenal insufficiency · Addison's disease · adrenal crisis · Cushing syndrome · Cushing disease · primary aldosteronism · Conn syndrome · phaeochromocytoma · paraganglioma · adrenal incidentaloma · hyperaldosteronism · hypocortisolism · secondary adrenal insufficiency · Waterhouse-Friderichsen syndrome
Consultant-physician-depth guide to adrenal disorders — adrenal physiology, Addison's disease (primary adrenal insufficiency) and adrenal crisis, secondary adrenal insufficiency, Cushing syndrome, primary aldosteronism (Conn syndrome), phaeochromocytoma, and the adrenal incidentaloma — structured for FRACP DWE and DCE, MRCP and ABIM preparation.
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Target exams
Red flags
- Adrenal crisis — hypotensive shock, vomiting, abdominal pain, confusion, hypoglycaemia in a patient with known or suspected adrenal insufficiency
- Suspected phaeochromocytoma with hypertensive crisis — never give beta-blockade first; unopposed alpha stimulation is dangerous
- Bilateral adrenal haemorrhage in an anticoagulated or septic patient — sudden back pain, hypotension, falling haemoglobin, hyponatraemia and hyperkalaemia
- Ectopic ACTH with severe hypokalaemic alkalosis and hyperpigmentation — search for small cell lung cancer
- Adrenal crisis precipitated by sudden withdrawal of chronic exogenous steroids or intercurrent illness in a steroid-dependent patient
- Waterhouse-Friderichsen syndrome — fulminant meningococcal septicaemia with bilateral adrenal haemorrhage and purpura
Adrenal Disorders
Meet the patient
A 42-year-old woman is brought to the emergency department vomiting, confused, and hypotensive at 80/40. She has been tired and losing weight for six months, is tanned in her palmar creases and buccal mucosa, and her sodium is 124, potassium 5.9. She has Hashimoto thyroiditis. The registrar is treating septic shock and has drawn cultures.[1][6]
The examiner's question: "What single bedside blood test before the fluid goes in, and what drug do you give immediately regardless of the result?" This is adrenal crisis in undiagnosed autoimmune Addison's — draw a random cortisol and ACTH, then give hydrocortisone 100 mg IV without waiting.[1][6]
References9ShowHide
- [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
- [2]Nieman LK, Biller BMK, Findling JW, et al. The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab, 2008.PMID 18334580
- [3]Funder JW, Carey RM, Mantero F, et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab, 2016.PMID 26934393
- [4]Lenders JWM, Duh QY, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline J Clin Endocrinol Metab, 2014.PMID 24893135
- [5]Fassnacht M, Tsagarakis S, Terzolo M, et al. European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors Eur J Endocrinol, 2023.PMID 37318239
- [6]Hahner S, Spinnler C, Fassnacht M, et al. High incidence of adrenal crisis in educated patients with chronic adrenal insufficiency: a prospective study J Clin Endocrinol Metab, 2015.PMID 25419882
- [7]Oldfield EH, Doppman JL, Nieman LK, et al. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing's syndrome N Engl J Med, 1991.PMID 1652686
- [8]Colao A, Petersenn S, Newell-Price J, et al. A 12-month phase 3 study of pasireotide in Cushing's disease N Engl J Med, 2012.PMID 22397653
- [9]Adler GK, Stowasser M, Correa RR, et al. Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2025.PMID 40658480