Early

Cortisol is the body’s stress-support hormone. During infection, trauma, surgery, vomiting, or severe pain, cortisol helps maintain vascular tone, supports the vasopressor response, 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. What makes the pattern dangerous is the combination of illness or stress with poor vascular tone, falling blood pressure, hypoglycemia, electrolyte disturbance, and worsening mental status. Chronic exogenous glucocorticoid therapy is a common and easily missed cause. Steroids given from outside the body suppress the hypothalamic-pituitary-adrenal axis, much like a thermostat that stops signalling when the room is already warm. Once the medication is reduced, stopped, or becomes insufficient for an acute stressor, the suppressed...