a teaspoon of hyperthermia + a tablespoon of adrenal crisis

Thank you to Lily Stern, who, post-nights on MICU, presented a fascinating case of a woman with hyperthermia thought 2/2 an adrenal crisis. The theme of these pearls is big props to my name sisters (Lily Stern and Rachel Greenblatt). They are not my flesh and blood sisters =)
Top pearls
  • the distinction between fever, hyperthermia and hyperpyrexia
  • in adrenal crisis give steroids, give fluids, and identify the underlying cause
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Fever, hyperthermia, hyperpyrexia

My predecessor, Rachel G, wrote GREAT pearls on hyperthermia vs fever that you can find here:
We were all struggling with the distinction between fever, hyperthermia, and hyperpyrexia. So I’ll reiterate that distinction here.
  • fever
    • hypothalamically driven increase in body temperature. The body increases its’ hypothalamic set point, circulating pyrogens increase, and then both behavioral and metabolic mechanisms are activated in response. This has both infectious and non-infectious causes.
  • hyperthermia
    • unchanged hypothalamic set point + some cause of elevated temperature. Some examples
      • heat stroke
      • toxidromes that impair sweating
      • serotonin syndrome and NMS
  • hyperpyrexia
    •  T>41.5, which is often non-infectious. Most common cause is CNS hemorrhage.

 

Adrenal Crisis

Pathophys and risk factors

  • people with adrenal crisis usually have both a vulnerability and a precipitating factor
  • vulnerability
  • commonly glucocorticoid and a mineralocorticoid deficiency but folks with isolated glucocorticoid deficiency, like those on chronic steroid therapy can also develop adrenal crisis.
  • Major categories
      • autoimmune adrenalitis
      • infections that have destroyed the adrenal glands (classically TB, fungi, AIDS)
      • mets to the adrenals
      • CAH
      • bilateral adrenal hemorrhage or ectomyprimary adrenal insufficiency
    • secondary adrenal insufficiency
      • pituitary or hypothalamic problem
        • tumor, surgery, radiation, lymphocytic hypophysitis, trauma
      • drugs that suppress the HPA axis
        • high dose progestins
        • high dose opioids (yet another risk of chronic, high dose opioid therapy)
    • tertiary adrenal insufficiency
      • long term glucocorticoid exposure
        • PO steroids are obvious culprits. Don’t forget about topical and inhaled steroids! I’m living proof that fluticasone in particular can  cause secondary AI (I’m better now =)
  • precipitating factors
    • 90% of people with adrenal crisis have a known precipitating event. Assume infection until proven otherwise
    • Major categories
      • Check out this list of causes from a review article on adrenal crisis (attached in the evernote)

causes-of-adrenal-crisis

  • most common: infection, gastroenteritis (preventing med absorption) and failure to increase steroid dose in response to stress
  • most unexpected: flight delays, wasp stings without anaphylaxis
Presentation
  • symptoms and signs
    • most common – weakness, AMS, abdominal pain, nausea, vomiting, hypotension and fever. The degree of temperature elevation can often be exaggerated.
  • lab abnormalities
    • hyponatremia, hyperkalemia, hypoglycemia, and hypercaclemia
Management (somewhat analogous to DKA management, except replace the word “insulin” with “steroids”)
  • don’t fret, just give IV steroids!
    • UpToDate recommends 4mg IV dexamethasone because it does not interfere with the serum cortisol assay. 100mg IV hydrocortisone is also grand. Just keep in mind that it does interfere with the assay.
    • if this is a new presentation of AI, send serum cortisol and serum ACTH from the blood drawn on admission.
  • give fluids
    • like you would in any other distributive shock
  • identify the precipitating cause
    • like in DKA, most crises are caused by infection. Have an extremely low threshold to antibiose!
Prevention
  • Recommend the following to outpatients vulnerable to adrenal crisis (from the UK Addison’s Self Help Group)
    • self-administration of stress dose steroids
      • if they fever, are sick, or are receiving antibiotics OR have severe nausea, stress, or physical injury, they should double their steroid dose until they recover. They should check in with you if they need to triple thei dose for >3 days.
      • if intractable vomiting, they should present promptly to an ED
        • IM hydrocortisone is available for those who don’t have ready access to medical care. People using IM hydrocortisone should still present to hospitals for a medical workup
      • Peri-procedural stress dose steroids are a must for anything bigger than a skin biopsy or dental filling, including dental surgery like a root canal. Dose depends on surgical size. Look these up if/when it’s relevant.
A side note 
 
 Who gets to decide what medical problems are classified as “crisis” when they are bad? It’s a random list, including…
  • myasthenic and cholinergic crisis
  • oculogyric crisis
  • lots of sickle cell complications (pain, splenic sequestration, aplastic)
  • scleroderma renal crisis
If you know of a rhyme or reason to this, let me know!
Citations
Puar TH1, Stikkelbroeck NM2, Smans LC3, Zelissen PM3, Hermus AR2. Adrenal Crisis: Still a Deadly Event in the 21st Century.Am J Med. 2016

Filed under: Morning Report

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