Occult hypoadrenalism in critically ill patients.

Abstract

The article by Baldwin and Allo 1 in the June 1993 issue of theArchivesdraws attention to the important but infrequently recognized problem of adrenal insufficiency in critically ill patients. The authors describe four patients with refractory shock who significantly improved after the infusion of doses of hydrocortisone that simulated physiologic stress response. We recently reported a similar syndrome in three elderly, poorly nourished, critically ill postoperative patients but postulated a different pathogenic mechanism. 2 Unexplained hypotension developed perioperatively in our paitents, and although hypotensive, they had inappropriately low plasma cortisol concentrations (276, 331, and 165 nmol/L). Despite normal responses to infusions of cosyntropin, these patients responded dramatically to the administration of glucocorticoids. Two of our patients had low serum thyroxine concentrations without increased thyrotropin levels and had depressed levels of gonadotropins. After recovery, serum thyroxine levels increased, gonadotropin levels reverted to normal, and a normal hypothalamic-pituitary-adrenal axis was