A patient with sepsis and hypotension unresponsive to fluids, vasopressors, and antibiotics presents with hyponatremia, hyperkalemia, hypochloremia, and elevated BUN and creatinine. What is the most likely cause?

• A. Acute adrenal insufficiency
• B. Septic shock refractory to therapy
• C. Acute kidney injury from hypovolemia
• D. Hyperkalemic crisis due to renal failure

Answer: (A)

Acute adrenal insufficiency presents with shock that is difficult to treat and a characteristic electrolyte pattern from mineralocorticoid deficiency. When aldosterone is lacking, the kidneys lose sodium and water, and cannot adequately excrete potassium. This leads to hyponatremia and hyperkalemia, often with volume depletion that raises BUN and creatinine. Cortisol deficiency further blunts vascular responsiveness to catecholamines, worsening hypotension despite fluids and vasopressors. The combination of unresponsive hypotension and the hyponatremia with hyperkalemia point to an adrenal crisis as the underlying cause.

Other scenarios like septic shock refractory to therapy describe the physiology of shock without a specific electrolyte signature, acute kidney injury from hypovolemia explains reduced kidney function but not the concurrent hyperkalemia with hyponatremia as cleanly, and a hyperkalemic crisis from renal failure centers on potassium elevation without the accompanying hyponatremia and the broader context of cortisol/aldosterone deficiency.