Emergency presentation with hypotension, hypoglycaemia and circulatory collapse due to acute glucocorticoid deficiency
A detailed and full general examination is mandatory in the initial assessment of an acutely unwell patient.
The patient with classical Addison's disease may have a deep tan, with buccal, scar and palmar pigmentation, and evidence of generalised weight loss.
The patient with hypopituitarism or hypothyroidism may have a typical appearance of waxy, doughy skin, thinned hair, cool peripheries, and reduced conscious level.
Detailed emergency cardiac assessment is necessary in the patient presenting with collapse.
The patient will usually be profoundly fluid depleted, with hypotension and a postural drop in blood pressure.
Deeply tanned skin with pigmentation of scars is indicative of classical Addison’s disease and high ACTH levels.
Pallor may also occur with anaemia and glucocorticoid deficiency of any cause, for example pernicious anaemia, coeliac disease or pituitary dysfunction.
Patches of symmetrical depigmentation of both hair and skin may occur with vitiligo.
Dry skin with diffuse hair loss may be seen in hypothyroidism or hypopituitarism, and fine wrinkling of the skin occurs in hypopituitarism.
Non-specific abdominal pain is commonly associated with an Addisonian crisis. However, underlying abdominal conditions may also have triggered the crisis. Acute adrenal infarction also causes severe abdominal pain which may mimic renal colic.