A 45-year-old woman with systemic lupus erythematosus has been on prednisolone 60 mg daily for 6 weeks. She presents to the emergency department with hypotension and fever. Her random serum cortisol is low. The most appropriate immediate management is:

• A Wait for ACTH stimulation test results before giving steroids
• B Administer fludrocortisone alone, as mineralocorticoid deficiency is the cause of hypotension
• C Start oral prednisolone at the previous dose and arrange outpatient endocrinology follow-up
• D Administer intravenous hydrocortisone immediately, as ACTH testing can be deferred in acute illness ✓

Explanation

In a patient on chronic glucocorticoids who presents with hypotension and possible adrenal insufficiency, IV hydrocortisone (100 mg bolus) should be given immediately without waiting for ACTH stimulation test results. Delaying treatment in adrenal crisis can be fatal. Chronic exogenous glucocorticoids suppress the HPA axis, and acute stress cannot be met by endogenous cortisol production. Fludrocortisone alone is inadequate as glucocorticoid replacement is the immediate priority. Oral therapy is inappropriate in a hypotensive patient.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.