Addisonian Crisis

It was an extremely interesting on-call yesterday.


At about 7 pm, I was called down to Resus in A&E. When I arrived, I saw this extremely drowsy but rousable girl. Her fingers were icy cold with mildly cyanosed fingers. Her blood pressure was in her boots; it was barely recordable! She was also tachycardic and tachypnoeic. Luckily her mother was around to provide us with some background information.


We soon found out that she was recently diagnosed with Addison's disease. She has been vomiting for nearly 1 week. She did not have any diarrhoea. Her mother insisted that the patient has been compliant with her daily steroid tablets. Addison's disease is a rare illness in which the adrenal gland fails to produce adequate steroid hormones. Steroid hormones are important to enable the body to function efficiently, especially at times of stress. Treatment for the illness would include replacing the steroid hormones by taking life long steroid tablets.


It was obvious that she was in Addisonian Crisis!! It is a potentially fatal illness. Immediately, she was given a dose of IV steroid, broad spectrum antibiotic to cover for possible sepsis (although I could not find a source of infection at that time), and fast fluids. Despite all the fluid challenges, her BP hardly responded.....at best, the reading was 40 systolic!!! I could hardly palpate her brachial or radial pulses. To make matters worse, she hardly passed any urine after 4L of fluid!! I understand that those with Addison's will have hypotension......but I was not sure whether her low BP was purely due to her Addison's, septic shock or simply dehydration.


At the end, I had to contact ITU for assistance, and subsequently, she was started on an infusion of noradrenaline to improve her BP. Fortunately, she responded well to this. Today, she was sitting up on her bed, happily chatting away, when I went to check on her. Her BP was 120/60 (obviously with help from noradrenaline).

The interesting thing about her was actually her chest x-ray. Her first chest x-ray when she was in resus was actually normal. There was no focal consolidation. However, after having a central inserted, another chest x-ray was requested in order to exclude a pneumothorax and check position of the central line. It was in this second x-ray that finally we saw the source of infection. She had severe bibasal consolidation! So, she definitely had a really bad pneumonia. Fortunately, she already received a dose of ceftriaxone, which is good in pneumonias.

However, I really do not understand why there was no consolidation in her first x-ray. I mean, it was only 2 hours difference between the 2 of them. One of the anaesthetics SHO believed that patients are too dehydrated and shock when they first arrive in the hospital. As fluids are provided, the body starts to fill up and as a result, the mucus pluggings in the chest start to loosen up, and hence, that's when the abnormality shows. I don't know how true this is....but it sounds a reasonable answer.

Anywho, she was a good case. She was my first Addisonian Crisis patient. The other interesting patient was an elderly gentleman who I believe presented with urinary sepsis. He was in acute renal failure, with a creatine of 786!! And he was profoundly metabolic acidotic with H+ of 80, bicarbonate of only 5! Also, he had amazing ECG changes due to his hyperkalaemia! There were wide QRS complexes and tall tented T waves. His potassium was 7.8. He must also be extremely septic. His urine looked like pus....it was thick, turbid and smelled horrible! urgh... never seen such a yucky looking urine ever!

It was a really busy on-call but surely exciting. On-call again tomorrow...hope it's a little better.