Hipertansif Kriz ile Başvuran Hastada Gözden Kaçabilecek Bir Tanı: Primer Adrenal Yetmezlik
Özet
Adrenal yetmezlik, acil servislerde genellikle hipotansiyon, hiponatremi ve kardiyovasküler kollaps ile başvuran hayatı tehdit eden bir endokrin acildir. Ancak, hipertansif kriz ile başvuru oldukça nadir görülür (%1-2) ve tanısal zorluklar yaratabilir. Bu vaka sunumunda, şiddetli baş ağrısı ve hipertansif acil (hipertansif kriz, end-organ hasarı olmadan) ile acil servise başvuran 67 yaşında erkek hasta sunulmaktadır. Başlangıçta hipertansif acil olarak değerlendirilen hastada, antihipertansif tedavi sonrası gelişen aşırı kan basıncı düşüşü, ortostatik hipotansiyon ve hiponatremi, altta yatan primer adrenal yetmezlik (akut adrenal kriz) tanısına yol açmıştır. Hastada instabilite bulguları ve adrenal kriz şüphesi nedeniyle tanı testleri (kosintropin stimülasyon testi) beklenmeden derhal intravenöz hidrokortizon tedavisi başlanmış, sonrasında yapılan kosintropin stimülasyon testi ile tanı doğrulanmış ve hidrokortizon replasman tedavisi ile hasta tam klinik iyileşme göstermiştir. Bu olgu, primer adrenal yetmezliğin atipik prezentasyonlarının farkında olunması, hipertansif kriz ile başvuran hastalarda açıklanamayan hiponatremi ve hiperkalemi varlığında adrenal yetmezliğin ayırıcı tanıda düşünülmesi gerektiğini ve acil tıp pratiğinde instabil hastalarda tanı testleri beklenmeden steroid tedavisinin başlanmasının hayati önemini vurgulamaktadır.
Referanslar
Pazderska A, Pearce SHS. Adrenal insufficiency–recognition and management. Clinical Medicine, 2017; 17(3): 258-262. https://doi.org/10.7861/clinmed.17-3-258
Dineen R, Thompson CJ, Sherlock M. Adrenal crisis: prevention and management in adult patients. Therapeutic Advances in Endocrinology and Metabolism, 2019; 10: 2042018819848218. https://doi.org/10.1177/2042018819848218
Hahner S, Ross RJ, Arlt W, et al. Adrenal insufficiency. Nature Reviews Disease Primers, 2021; 7(1): 19. https://doi.org/10.1038/s41572-021-00252-7
Shaikh MG, Boyes L, Kingston H, et al. Adrenal Failure: An Evidence-Based Diagnostic Approach. Diagnostics, 2023; 13(10): 1812. https://doi.org/10.3390/diagnostics13101812
Alvear A. Addison's disease: a comprehensive narrative review of pathophysiology and clinical management. Global Journal for Research Analysis, 2024; 13(6): 91-94. https://doi.org/10.36106/gjra/9106914
Lentz S, Roginski MA, Montrief T, et al. Diagnosis and Management of Adrenal Insufficiency and Adrenal Crisis in the Emergency Department. The Journal of Emergency Medicine, 2022; 63(3): 313-323. https://doi.org/10.1016/j.jemermed.2022.06.005
Gültekin MU, Şahin E, Özkan S, et al. Adrenal Crisis: From Perioperative Clinic to Diagnosis. Cureus, 2025; 17(1): e88971. https://doi.org/10.7759/cureus.88971
Al-Abdouh A, Bizanti A, Barbarawi M, et al. A Challenging Case of Adrenal Insufficiency Presenting with Hypertensive Crisis. Research in Health Science, 2020; 5(1): 35-40. https://doi.org/10.22158/rhs.v5n1p35
Nwaneri C. Is this Acute Manifestation of Adrenal Crisis? Acta Medica International, 2025; 12(1): 1-3. https://doi.org/10.4103/amit.amit_89_24
Fadial M. Differential diagnosis of adrenal crisis. Emergency Medicine News, 2022; 44(6): 22. https://doi.org/10.1097/01.eem.0000832492.77503.d2
Younes YK, Viardot A. Latent Adrenal Insufficiency: From Concept to Diagnosis. Frontiers in Endocrinology, 2021; 12: 720769. https://doi.org/10.3389/fendo.2021.720769
He W, Goodkind D, Kowal P. Diagnosis and Management of Adrenal Insufficiency. In: An Aging World: 2015. Washington, DC: U.S. Census Bureau; 2018. p. 125-142. https://doi.org/10.1007/978-3-319-62470-9_9
Dávila-Aranda JA, Dávila-Aranda RA, Dávila-Aranda RD. Diagnóstico tomográfico de tuberculosis adrenal primaria en enfermedad de Addison en la altitud. Reporte de caso. Revista de la Facultad de Medicina Humana, 2020; 20(4): 702-706. https://doi.org/10.25176/rfmh.v20i4.2953
Howarth AR, Gunganah K, Whitaker MJ, et al. Heterogeneous natural history of Addison's disease: mineralocorticoid deficiency may predominate. Endocrine Connections, 2022; 11(11): e220305. https://doi.org/10.1530/ec-22-0305
Puar THK, Stikkelbroeck NMML, Smans LCCJ, et al. Managing Adrenal Insufficiency and Crisis. In: Adrenal Disorders. Singapore: Springer; 2018. p. 485-502. https://doi.org/10.1007/978-981-10-1124-5_34
Zhao Y, Wang Y, Zhao Y, et al. Severe hypertension caused by 17α-hydroxylase deficiency: A case report. Heliyon, 2023; 9(3): e14062. https://doi.org/10.1016/j.heliyon.2023.e14062
Jahan N. A 25-Year-Old Male with Suspected Adrenal Crisis and Hyperpigmentation. Journal of Clinical Case Reports, 2019; 9(3): 1245.
Lewis JE, Seckl JR, Gibb FW. Diagnosis and management of adrenal insufficiency. Clinical Medicine, 2023; 23(4): 336-340. https://doi.org/10.7861/clinmed.2023-0067
Arlt W. SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of acute adrenal insufficiency (adrenal crisis) in adult patients. Endocrine Connections, 2016; 5(5): G1-G3. https://doi.org/10.1530/ec-16-0054
Mufeeth M, Shetty S, Rao P. Unmasking Addison's Disease: A Case of Acute Adrenal Crisis. Journal of the Association of Physicians of India, 2025; 73: 1131. https://doi.org/10.59556/japi.73.1131
Llahana S, Follin C, Yedinak C, et al. Diagnosis and Management of Adrenal Insufficiency in Children and Adults. In: Advanced Practice in Endocrinology Nursing. Cham: Springer; 2019. p. 637-656. https://doi.org/10.1007/978-3-319-99817-6_37
Quinkler M, Ekman B, Marelli C, et al. Characterization of patients with adrenal insufficiency and frequent adrenal crises. European Journal of Endocrinology, 2021; 184(5): 691-698. https://doi.org/10.1530/eje-20-1324
