A 71-year-old woman with shock and a high INR

Raja Y. Zaghlol; Michael E. Tierney; Louay Y. Zaghlol; Ayman A. Zayed

doi:10.3949/ccjm.85a.17031

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Figure 1
Adrenal insufficiency is classified according to whether the defect lies in the adrenal gland (primary adrenal insufficiency) or centrally, ie, in the pituitary gland (secondary adrenal insufficiency) or hypothalamus (tertiary adrenal insufficiency).

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TABLE 1

Initial laboratory results

Test	Value^a	Reference range
Serum sodium	128 mmol/L	135–145 mmol/L
Serum potassium	5.8 mmol/L	3.5–5.2 mmol/L
Serum chloride	100 mmol/L	97–107 mmmol/L
Serum creatinine	1.3 mg/dL	0.5–1.1 mg/dL
Blood urea nitrogen	35 mg/dL	7–20 mg/dL
Serum glucose (random, not fasting)	194 mg/dL	70–140 mg/dL
Alanine aminotransferase	18 IU/L	7–35 IU/L
Serum albumin	4.0 g/dL	3.5–5.5 g/dL
Hemoglobin	10.1 g/dL	12.3–15.3 g/dL
Mean corpuscular volume	85 fl	80–100 fl
Mean corpuscular hemoglobin	28 pg/cell	26–34 pg/cell
Mean corpuscular hemoglobin concentration	32.5 g/dL	31–36 g/dL
White blood cell count	11.0 × 10⁹/L	4.5–11.0 × 10⁹/L
Neutrophils	67%	40%–75%
Lymphocytes	24%	20%–45%
Monocytes	3.5%	2%–10%
Eosinophils	5.0%	1%–6%
Basophils	0.5%	0%–1%
Platelet count	220 × 10⁹/L	150–400 × 10⁹/L
International normalized ratio	6.13	2.0–3.0^b
Partial thromboplastin time	35 seconds	30–40 seconds
Arterial partial pressure of oxygen	76 mm Hg	78–84 mm Hg (predicted for age)
Oxygen saturation	94%
Arterial partial pressure of carbon dioxide	30 mm Hg	35–45 mm Hg
Serum bicarbonate	18 mmol/L	22–26 mmol/L
Blood pH	7.34	7.35–7.45

↵a Abnormal results are shown in bold.
↵b Therapeutic range for patients on warfarin for atrial fibrillation.

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TABLE 2

Clinical manifestations of adrenal insufficiency by organ system^a

General
Fatigue, generalized weakness
Muscle weakness
Muscle and joint pain
Loss of appetite
Weight loss
Fever^b

Gastrointestinal
Nausea and vomiting
Abdominal pain
Acute abdomen with tenderness and rigidity^b
Constipation or diarrhea
Salt craving^c

Dermatologic
Hyperpigmentation of skin, mucous membranes, hair, and nails^c
Vitiligo^c
Dry, itchy skin
Auricular cartilage calcification (males)

Cardiovascular
Shock^b
Intravascular volume depletion
Hypotension/orthostatic hypotension
Tachycardia/orthostatic tachycardia
Tachypnea

Neuropsychiatric
Dizziness, postural dizziness
Depression^d
Memory impairment^d
Psychosis (rare)^d
Confusion^b
Decreased level of consciousness^b

Reproductive (women):
Decreased axillary and pubic hair
Decreased libido
Amenorrhea

Endocrine
Autoimmune endocrine disorders,^c eg, hypothyroidism
Other pituitary hormonal abnormalities^e

↵a Clinical manifestations depend on rate of onset and severity of adrenal insufficiency.
↵b Only in adrenal crisis.
↵c Only in primary adrenal insufficiency.
↵d Only in long-standing adrenal insufficiency.
↵e Only in secondary or tertiary adrenal insufficiency.

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TABLE 3

Major causes of adrenal crisis

Adrenal necrosis due to:
Adrenal hemorrhage
Sepsis
Emboli
Blunt trauma

Sudden withdrawal of corticosteroids in a patient who is steroid-dependent

Deterioration of previously undiagnosed adrenal insufficiency after major stress, eg, severe infection

Failure to increase corticosteroid dosage in steroid-dependent patients on days of major stress, eg, severe infection, surgery^a

Acute secondary or tertiary adrenal insufficiency, eg, pituitary apoplexy

↵a Some animal studies suggest that continuing the maintenance dose of glucocorticoids is adequate to prevent adrenal crisis. It is common practice to provide stress doses of glucocorticoids during an acute illness.

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TABLE 4

Laboratory findings in adrenal insufficiency

Hyponatremia

Hyperkalemia^a

Hypercalcemia

Hypoglycemia

Normal anion gap metabolic acidosis^a

Azotemia (prerenal)^a

Anemia (normochromic normocytic)

Relative lymphocytosis

Eosinophilia

Mild elevation in serum thyroid-stimulating hormone

Autoantibodies against 21-hydroxylase antigen^a

↵a May be present only in primary adrenal insufficiency.

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TABLE 5

Clinical features of primary vs central (secondary, tertiary) adrenal insufficiency

Feature	Primary	Central	Possible explanation for difference
Skin hyperpigmentation	Yes	No	Adrenocorticotropic hormone production and thus melanocyte-stimulating hormone levels are increased in primary but not central adrenal insufficiency
Gastrointestinal symptoms	More prominent	Less prominent	More prominent electrolyte disturbances in primary adrenal insufficiency may play a role in gastrointestinal symptoms
Intravascular volume depletion, hypotension	More prominent	Less prominent^a	Decreased serum aldosterone levels only in primary adrenal insufficiency
Hyperkalemia	Yes	No	Decreased serum aldosterone levels only in primary adrenal insufficiency
Hypoglycemia	Less prominent	More prominent	Concomitant growth hormone deficiency present in some cases of central adrenal insufficiency More insidious progression in central adrenal insufficiency resulting in delayed presentation and more prominent corticosteroid deficiency symptoms such as hypoglycemia
Blood urea nitrogen elevation	More frequent	Less frequent	Intravascular volume depletion resulting in prerenal azotemia is present more frequently in primary adrenal insufficiency
Hypopituitarism, headaches, visual field defects	No	Yes	Depends on the underlying cause

↵a Secondary adrenal insufficiency such as pituitary apoplexy may present with hypotension and, if not treated, may lead to azotemia. However, this may occur much more frequently in patients with primary adrenal insufficiency.