Recognition and Management of Adrenal Emergencies

Cortisol: Analytical and clinical determinants

Cortisol, the main human glucocorticoid, is synthesized from cholesterol in the adrenal cortex and predominantly metabolized by the liver. Interpretation of quantitative results from the analysis of serum, urine and saliva is complicated by variation in circadian rhythm, response to stress as well as the presence of protein-bound and free forms. Interestingly, cortisol is the only hormone routinely measured in serum, urine, and saliva. Preanalytical and analytical challenges arise in each matrix and are further compounded by the use of various stimulation and suppression tests commonly employed in clinical practice. Although not yet included in clinical guidelines, measurement of cortisol in hair may be of interest in specific situations. Immunoassays are the most widely used methods in clinical laboratories to measure cortisol, but they are susceptible to interference from synthetic and endogenous steroids, generally producing a variable overestimation of true cortisol results, especially in urine. Analysis by mass spectrometry provides higher specificity and allows simultaneous measurement of multiple steroids including synthetic steroids, thus reducing diagnostic uncertainty. An integrated review of cortisol in various disease states is also addressed.

Fever with Multiple Organ Failure: Not Always Sepsis

We present the case of a 52-year-old female admitted with fever and multiple organ failure, initially treated for presumed sepsis. However, the combination of multiple organ failure, hyperthermia and vascular instability raised the suspicion of a phaeochromocytoma multisystem crisis. An emergency abdominal ultrasound in the intensive care unit disclosed a large tumour of the right adrenal. Despite specific medical treatment for the presumed adrenal emergency and multiple organ failure, the patient succumbed. Postmortem examination verified the diagnosis of phaeochromocytoma.

Pheochromocytoma: challenges in diagnosis and nursing care

Pheochromocytomas are catecholamine-secreting tumors arising from chromaffin cells of the sympathoadrenal system, which includes the adrenal medulla and sympathetic ganglionic tissue. The effects of catecholamine excess cause potentially fatal symptomologies and end-organ damage if not diagnosed and treated. If diagnosed and removed surgically, most of these patients can be cures. Pheochromocytomas are rare and affect from two to eight per million people. There are 800 deaths in the United States annually as a result of complications. Of patients who have pheochromocytomas diagnosed at autopsy, 75% died suddenly from myocardial infarction or cerebral vascular catastrophe. Challenges in diagnosis, tumor location, and treatment are considerable.

Acute adrenal insufficiency

Adrenal insufficiency is a rare disorder, usually with gradually evolving clinical symptoms and signs. Occasionally, an acute adrenal insufficiency crisis can become a life-threatening condition because of acute interruption of a normal or hyperfunctioning adrenal or pituitary gland or sudden interruption of a adrenal replacement therapy. Acute stress situations can aggravate the symptomatology. A simple strategy or diagnostic screening and early intervention with sodium chloride-containing fluids and hydrocortisone should be widely implemented for cases with suspicion of an acute Addison disease crisis. In contrast, the chronic replacement dosage for patients with adrenal insufficiency should be as low as possible with clear instructions for dosage adjustments in case of stress or acute emergencies.