Early

Cortisol is a stress-response hormone. During infection, trauma, surgery, vomiting, or severe pain, cortisol helps maintain vascular tone, supports the response to vasopressors, promotes glucose availability, and helps the body tolerate physiologic stress. Adrenal insufficiency occurs when the body cannot produce enough cortisol. In primary adrenal insufficiency, the adrenal glands fail directly. Aldosterone deficiency may occur as well, causing sodium loss, volume depletion, and hyperkalemia. In central or glucocorticoid-induced adrenal insufficiency, ACTH stimulation is reduced; aldosterone is often preserved, so hyperkalemia may be absent. An adrenal crisis is acute, life-threatening cortisol deficiency. The patient may initially appear to have gastroenteritis, dehydration, sepsis, or medication-related hypotension. The dangerous pattern combines illness or stress with poor vascular tone, falling blood pressure, hypoglycemia, electrolyte disturbance, and worsening mental status. Exogenous glucocorticoid therapy is a common and easily missed cause. Glucocorticoids suppress the hypothalamic-pituitary-adrenal axis. If the medication is reduced, stopped, or becomes insufficient during acute stress, the suppressed adrenal system may not respond quickly enough. Risk from oral glucocorticoid exposure is expected when both exposure thresholds are exceeded: a duration of 3–4 weeks...