Adrenal crisis.

In the case study presented in this article, the patient had many of the historical risk factors for bilateral adrenal hemorrhage that Rao outlined. He had recently undergone surgery and was receiving heparin for anticoagulation for a thromboembolic event. Further clues included his fever, hypotension refractory to pressors, and abdominal discomfort. In addition, he had received a blood transfusion in the early 1980s, putting him at risk for the development of human immunodeficiency virus infection. His low baseline cortisol level and the lack of ACTH stimulation confirmed the diagnosis of adrenal insufficiency, probably on the basis of bilateral adrenal hemorrhage given his presentation. Although true adrenal insufficiency is an uncommon event in the intensive care unit, the question of its presence is often considered. In addition, the use of exogenous glucocorticoids is so widespread that the possibility of secondary adrenal insufficiency is a frequent concern. Careful history taking and physical examination complemented by review of the laboratory data and the awareness of certain risk factors should help identify most cases. However, the presentation is often not classical and empiric therapy may be required while awaiting results of diagnostic testing.