Working Diagnosis:
1. Early manifestation of an adrenal crisis
2. Hyponatremia secondary to primary adrenal insufficiency

Treatment:
Most patients with primary adrenal insufficiency require stress dosing of steroids
during illness. However, there are limited recommendations for stress dosing during endurance
races. This patient, largely through his own trial and error during training, has developed a stress
dose regimen for race day. This includes: Liquid IV, fludrocortisone 0.1 mg, prednisone 5 mg,
hydrocortisone 20 mg before the swim, 25 mg before the bike and 30 mg before the run, and salt
tablets. In the medical tent, the patient's symptoms dramatically improved after oral hydration
and an additional 20mg of hydrocortisone.

Outcome:
The patient recovered after staying in the medical tent for about an hour and was able
to walk away of his own volition. In discussion with the patient several months after his race, he
reports no long-term effects from that race day. He acknowledges that finding the right stress
dosage is still a challenge for him. However, he continues to be able to race triathlons

Author's Comments:
This case provides a unique example of a high-level triathlete with adrenal insufficiency. The
primary manifestations of an adrenal crisis include profound weakness/fatigue, abdominal pain,
anorexia, and in severe forms shock. His weakness at the finish line seems likely secondary to an
early manifestation of an adrenal crisis. Additionally, high level endurance exercise has been
known to commonly precipitate hyponatremia given increased fluid intake while racing. This
patient is already predisposed to hyponatremia with his history of adrenal insufficiency and he
likely was experiencing side effects of this following the race.

Editor's Comments:
This case not only illustrates the complexity of adrenal insufficiency but also showcases the importance of proper pre-participation screening/medical histories or disclosures for high level mass events as well as knowing the level of care you are providing at these events. As discussed in the author's comments, this patient is more at risk for hyponatremia and other complications than the general population. Without having access to adequate testing or labs these conditions could be worsened with common treatments such as IV fluids. Knowing the agreed upon scope of management and available resources allows for safe and efficient treatment of injuries and illness at mass events. Luckily, this patient was well informed on their medical history and self-aware of their symptoms which enabled them to manage their own disorder. In another, this condition could have resulted in a catastrophic event, with the patient presenting obtunded and needing immediate transport. This serves as a strong reminder to know and practice your emergency action plan.

References:
Bonnecaze AK, Reynolds P, Burns CA. Stress-Dosed Glucocorticoids and Mineralocorticoids Before Intensive Endurance Exercise in Primary Adrenal Insufficiency. Clin J Sport Med. 2019 Nov;29(6):e73-e75. doi: 10.1097/JSM.0000000000000540. PMID: 31688185.

Elshimy G, Chippa V, Kaur J, et al. Adrenal Crisis. [Updated 2023 Sep 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499968/

Jonas CE, Arnold MJ. Exercise-Associated Hyponatremia: Updated Guidelines from the Wilderness Medical Society. Am Fam Physician. 2021 Feb 15;103(4):252-253. PMID: 33587580.

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