Relative Adrenal Insufficiency in the Critical Care Setting: Debunking the Classic Myth

Kromah, Fatuma; Tyroch, Alan; McLean, Susan; Hughes, Harold; Flavin, Nina E.; Lee, So‐Young

doi:10.1007/s00268-011-1126-3

Cited by 13 publications

(5 citation statements)

References 30 publications

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“…In a series of 108 patients with idiopathic adrenal insufficiency, only 6 (5.5%) patients were complicated by mild hypercalcemia (9). In a recent study, although 112 (53%) of the 212 ICU patients were diagnosed as having latent adrenal insufficiency, no patients developed overt hypercalcemia (10). In this study, we found the prevalence of hypercalcemia due to adrenal insufficiency to be 1.3% in HD patients at a tertiary hospital.…”

Section: Discussionmentioning

confidence: 44%

Clinical Manifestation of Hypercalcemia Caused by Adrenal Insufficiency in Hemodialysis Patients: A Case-series Study

et al. 2014

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Objective The goal of this study was to clarify the clinical manifestation of hypercalcemia due to hypoadrenalism in hemodialysis (HD) patients. Methods We retrospectively analyzed the clinical characteristics of five HD patients who had presented with hypercalcemia due to adrenal insufficiency (age: 69±7 [58-75] years old, time on HD: 13±11 [2-32] years). We conducted corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) stimulation tests. We also examined serum bone turnover markers before and after glucocorticoid replacement. Results All patients had critical illnesses at the onset of hypercalcemia. They had at least one symptom, such as eosinophilia, hypoglycemia, or fever. The prevalence of hypercalcemia due to adrenal insufficiency was 1.3% in maintenance HD patients on admission. The causes of adrenal insufficiency were isolated ACTH deficiency, pituitary apoplexy, pituitary atrophy, glucocorticoid withdrawal syndrome, and unilateral adrenalectomy. Serum calcium (Ca) levels corrected by serum albumin were maximally increased to 12.9 to 14.3 mg/dL in four anuric HD patients and mildly elevated to 10.4 mg/dL in a patient with residual diuresis. Their basal serum cortisol levels ranged from <1.0 to 15.4 μg/dL. Single CRH injections failed to increase serum cortisol in any of the patients. Glucocorticoid replacement acutely normalized serum Ca and decreased levels of carboxy-terminal telopeptide of type I collagen, a marker of bone resorption. Conclusion Adrenal insufficiency could therefore be an occult cause of hypercalcemia in anuric HD patients who are critically ill.

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Section: Discussionmentioning

confidence: 44%

Clinical Manifestation of Hypercalcemia Caused by Adrenal Insufficiency in Hemodialysis Patients: A Case-series Study

et al. 2014

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“…Hypercalcemia in adrenal insufficiency is usually mild to moderate [ 4 - 5 ]. In a recent study, 53% of 212 intensive care unit patients were diagnosed with latent adrenal insufficiency, but none of these patients developed overt hypercalcemia [ 6 ]. The unusual feature of this case was the severe hypercalcemia.…”

Section: Discussionmentioning

confidence: 99%

A Case of Acute Adrenal Insufficiency: A Rare but Possible Cause of Hypercalcemia

Aynaou¹,

Salhi²,

Ouahabi³

2022

Cureus

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A 30-year-old woman presented with a 15-day history of epigastric pain, nausea, vomiting, asthenia, and weight loss. On admission, hypercalcemia was reported with a negative etiologic workup (including no primary hyperparathyroidism, malignancy, or vitamin D toxicity). Fluid replacement did not improve her hypercalcemia. We performed a blood ionogram and assessed the adrenocortical function, which showed that her serum cortisol was decreased, her adrenocorticotropic hormone (ACTH) was elevated, and anti-21 hydroxylase antibodies were positive. We established the diagnosis of autoimmune primary acute adrenal insufficiency. The patient was treated with hydrocortisone. Shortly after initiating the treatment, her serum calcium levels returned to normal and her symptoms improved. This case report highlights the fact that even though adrenal insufficiency is an uncommon etiology of hypercalcemia, it should not be totally ignored, especially since hypercalcemia can sometimes be indicative of adrenal impairment.

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“…Corticosteroids lead to eosinopenic effects by stimulating eosinophil apoptosis. The presence of eosinophilia in critically ill patients is associated with clinical signs of adrenal insufficiency (5). All albumin levels were >2.5 mg/dL.…”

Section: Patient Characteristicsmentioning

confidence: 99%

“…This condition is called critical illness-related corticosteroid insufficiency or relative adrenal insufficiency (RAI) (4). Clinically apparent adrenal insufficiency is usually rare in critically ill patients (5). Adrenal function is usually assessed by measuring the serum concentrations of total cortisol, free cortisol, or salivary cortisol levels (6).…”

Section: Introductionmentioning

confidence: 99%

Evaluation of the Hypothalamic-Pituitary-Adrenal Axis in a Paediatric Intensive Care Unit

et al. 2019

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Background. Relative adrenal insufficiency (RAI) is the inadequate production of cortisol due to dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis during a severe illness. We evaluated the HPA axis and RAI in a tertiary pediatric intensive care unit (PICU).Methods. A total of 100 PICU patients were included in this prospective cohort study. Basal serum levels of adrenocorticotropic hormone (ACTH), cortisol values were compared with those in the control group. A low-dose ACTH stimulation test was performed in patients with basal cortisol levels below 18 µg/dL.Results. The basal cortisol levels of the PICU patients were significantly higher than those of the control group (P < 0.05). All tested patients (n= 24) had delta cortisol levels > 9 µg/dL and a peak cortisol response > 18 µg/dL. Basal cortisol levels were positively correlated with Pediatric Risk of Mortality (PRISM) III scores (P < 0.05; r = 0.363). The basal or stimulated cortisol levels of the patients who received glucocorticoid treatment were higher than the cut-off levels.Conclusions. High basal or stimulated cortisol levels are indicative of disease severity in the acute phase of stress. Patients with very high cortisol levels should be particularly carefully monitored because of the high mortality risk.

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Relative Adrenal Insufficiency in the Critical Care Setting: Debunking the Classic Myth

Abstract: Hyponatremia, hyperkalemia, hypercalcemia, and hypoglycemia do not predominate in RAI and laboratory values are of minimal value in predicting patients with RAI.

Cited by 13 publications

References 30 publications

Clinical Manifestation of Hypercalcemia Caused by Adrenal Insufficiency in Hemodialysis Patients: A Case-series Study

Clinical Manifestation of Hypercalcemia Caused by Adrenal Insufficiency in Hemodialysis Patients: A Case-series Study

A Case of Acute Adrenal Insufficiency: A Rare but Possible Cause of Hypercalcemia

Evaluation of the Hypothalamic-Pituitary-Adrenal Axis in a Paediatric Intensive Care Unit

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