Acute adrenal insufficiency: recognition, management, and prevention.

Acute adrenal insufficiency may present only with nonspecific symptoms and signs. Hyperpigmentation is not a feature of secondary adrenal insufficiency and is absent in patients with primary adrenal failure of recent or acute onset. Similarly, characteristic electrolyte disturbances may be obscured by concomitant vomiting and diarrhea as well as by parenteral electrolyte replacement. A high index of suspicion must therefore be maintained to make the diagnosis of acute adrenal insufficiency in patients without a recognized history of autoimmune adrenal insufficiency or of other diseases or therapeutic regimens known to result in pituitary-adrenal failure. Timely intervention with volume and glucocorticoid replacement rapidly reverses all symptoms and signs of adrenal insufficiency. Guidelines are presented for glucocorticoid replacement in the treatment of adrenal crisis as well as for the prevention of acute adrenal insufficiency in patients with known or suspected pituitary-adrenal disease. In addition, recommendations are given for the simultaneous diagnosis and treatment of adrenal insufficiency in patients without previously established disease.