Volume 214 - Issue 7
Sepsis and adrenal insufficiency: a potentially lethal combination
Authors: Peter S Hamblin, Bu B Yeap and David J Torpy
Med J Aust 2021; 214 (7): 334-334.e1. || doi: 10.5694/mja2.50993
Published online: 19 April 2021
Published online: 19 April 2021
To the Editor: The Coroners Court of Victoria made several recommendations in 2020 after a 38‐year‐old man died alone at home.1 The cause of death was determined to be sepsis in the setting of an adrenal crisis.
The key coronial recommendations1 were to emphasise to the general medical community the non‐specific nature of symptoms of impending adrenal crisis (eg, fatigue, nausea, loss of appetite, vomiting),2 to record the diagnosis of adrenal insufficiency prominently as an alert in medical records,3 and to encourage endocrinologists to provide sick day or steroid stress dosing letters to patients, general practitioners, and family members and carers.
The Endocrine Society of Australia (ESA) endorses these recommendations. A standard patient letter has been developed and is now available on the ESA’s Hormones Australia website.4 We strongly support medical record alerts for the diagnosis of cortisol deficiency due to Addison disease or hypopituitarism.
It is crucial for doctors to have a high index of suspicion for the possibility of impending adrenal crisis in a patient with known adrenal insufficiency. The clinical syndrome evolves from acute adrenal insufficiency with symptoms of malaise, nausea and lethargy — all of which are non‐specific and may be considered part of another pathological process — to adrenal crisis, which is associated with hypotension initially manifest by postural blood pressure falls greater than 20 mmHg.2,3
Prevention involves advice on stress dosing:1 triple glucocorticoid dosing for 3 days (ie, the 3 × 3 rule),2 parenteral hydrocortisone at home (SOLU‐CORTEF Act‐O‐Vial, Pfizer) when unable to take tablets,3 and the availability of personal alerts (eg, a MedicAlert bracelet [MedicAlert Foundation], a steroid card) when the person is delirious or very unwell (Box).
The incidence of adrenal crises is increasing in Australia.3 Missed cases or failure to treat them because of overestimation of the risks of glucocorticoid therapy are unfortunately too common.
Box – Practical steps to reduce the risk of adrenal crisis
Ensure that others are aware of the diagnosis of established adrenal insufficiency |
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Have a high index of suspicion for an impending adrenal crisis |
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Prevent an adrenal crisis in patients with established adrenal insufficiency |
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Promptly treat an impending adrenal crisis |
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GP = general practitioner. * Some authorities recommend the off‐label use of a subcutaneous injection as this is easier for patient and/or carer to administer. | |||||||||||||||
Competing interests
No relevant disclosures.
References
- Coroners Court of Victoria. https://www.coronerscourt.vic.gov.au/sites/default/files/2020-02/FrancisJohnStewart_351518.pdf (viewed Aug 2020).
- 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; 100: 407–416.
- Rushworth RL, Torpy DJ, Falhammar H. Adrenal crisis. N Engl J Med 2019; 381: 852–861.
- Endocrine Society of Australia. Adrenal insufficiency advice for patients and doctors: sick day management for patients on glucocorticoid therapy. https://www.hormones-australia.org.au/wp-content/uploads/2020/11/Sick-Day-Management-Plan-FINAL-fillable.pdf (viewed Aug 2020).