A 34 years old woman, who has documented autoimmune primary adrenal insufficiency on prednisolone 5 mg daily, develops an acute abdominal pain. On evaluation it is seen that she has right iliac fossa tenderness and a CT scan of the lower abdomen shows inflamed appendix in the verge of bursting. It is decided to open her up immediately to remove the inflamed appendix.

1. The status of the axis is uncertain in this woman
2. It is maximally stressed and secreting high levels of ACTH and cortisol
3. It is maximally stressed and secreting high levels of ACTH but no cortisol
4. The axis is impaired in this woman and hence does not respond to the stress.

Answer: The right answer is (c). This woman has autoimmune destruction of the adrenals. She has a normally functioning pituitary and hypothalamus. Thus under the condition of acute abdomen and stress her hypothalamo pituitary adrenal axis is under maximal stress and it is secreting high levels of ACTH. But there is inadequate cortisol response.

1. Methylprednisolone 10-15 mg intravenously before opening her abdomen and tapering dose over the next couple of days to normal oral dose
2. Hydrocortisone 50-75mg intravenously preoperatively and continue postoperatively for 1 week and then switch over to a higher oral dose of prednisolone.
3. No need for preoperative dose of steroids. Start methylprednisolone 15-20mg postoperatively and continue for 2 days. Then switch to oral dose.
4. One single dose of methylprednisolone 15-20mg during surgery. Then switch to oral dose after 2 days.