Doctors from different countries have engaged in a stimulating debate around Mrs Barroso’s case. When Mrs Barroso presented to the emergency room, her haemodynamic stability was restored after a steroid bolus, clearly pointing to adrenal gland involvement, and we agree with most of the respondents on bmj.com that acute adrenal insufficiency was the likely diagnosis at presentation.1 Unfortunately, rapid measurement of serum cortisol and adrenocorticotropic hormone was not available at our laboratory at the time. Her dramatic and progressive haemodynamic deterioration demanded a prompt therapeutic decision, and we administered steroids even though other data such as the normal electrolyte …