Adrenal insufficiency

Dipesh Ludhwani M.D.

Internal Medicine Resident.
Rosalind Franklin University Centegra Hospital
 Introduction
• Sub-optimal functioning of adrenal cortex
(GFR).
• Primary vs secondary/tertiary
• Addison’s disease-Thomas Addison
– Initially thought as caused by TB.
 Causes of Adrenal Insufficiency
• Primary (Adrenal
involved)
– Autoimmune adrenalitis
– Infection
TB, Mycosis, Bacterial, HIV
associated
– Metastatic cancer
– Medications (Etomidate,
Ketoconazole,
Metyrapone)
– Adrenal Hemorrhage
• Central (pituitary and
hypothalamus involved)
-Exogenous corticosteroid
administration.
-Hypothalamic and Pituitary
disease like adenoma,
craniopharyngioma,
hypothalamic tumors,
sarcoidosis.
-Cranial irradiation.
-Drugs with CS activity
(Megestrol acetate)
 Signs and symptoms
• Fatigue(84-95%)
• Weight loss (66-76%)
• Nausea, vomiting, Abdominal pain(49-62%)
• Muscle and Joint pain(35-40%)
• Decreased libido (Women>Men)
• Psychiatric issues : Depression (20-40%),
Mania, Organic brain syndrome(5-20%),
Psychosis, Anxiety, Hallucinations.
 DIFFERENCE!!
• Primary • Secondary
– Hyperpigmentation,
Dehydration,
Hypotension, Low basal
serum cortisol level (<5.0
mcg/dl ) with a
suboptimal response
(<18.5 mcg/dl) to
cosyntropin, high ACTH
levels
– High Plasma Renin and
K+
– Normal pigmentation,
Normal volume, mild
changes in blood
pressure, Low cortisol
levels with low or
inappropriately normal
ACTH level.
– Normal Aldosterone and
Plasma renin activity,
with normal potassium
levels.
 Other Labs
• Low serum DHEA and DHEA-S
• Hyponatremia, Azotemia, anemia,
hypoglycemia, leukopenia with eosinophilia.
• Hypoglycemia (central>primary)
• Other Autoimmune deficiencies like
thyroiditis, Type I Diabetes, Vitiligo.
 Diagnosis
• Serum Cortisol level
– Morning serum
– Morning salivary
– Afternoon serum
– Urinary cortisol level
• ACTH stimulation test
– Standard high dose test
– Low dose test
 Addison’s Crisis
• Acute adrenal insufficiency
• Causes
– Major stress, illness
– Under dosed
– failure to take increased dose in illness
– Bilateral infarction/hemorrhage
– Abruptly stopping steroids in long term users
– Pituitary infarction/apoplexy
 S/S of crisis
• Presents as Hypotension or shock
• GI : Abdominal tenderness (PAS), nausea,
vomiting, diarrhea.
• Electrolyte abnormalities.
• Fever, may be exaggerated.
• Neuropsychiatric symptoms.
 Management:
STEROIDS, STEROIDS, STEROIDS
• Acute phase:
– IVF : 1-3L NS, use 5%D if hypoglycemic.
– If no known dx of AD, consider using dexamethasone
(does not affect serum cortisol levels), hydrocortisone
equally efficacious.
– Known cases of AD, hydrocortisone preferred.
– Start with IV bolus of either 4mg decadron or 100mg
solu-cortef, after initial bolus continue 50mg IV bolus
of hydrocortisone till symptoms improve, vitally stable
or able to tolerate orally.
– Look and treat for cause (infection, hemorrhage,
infarction)
 Polyglandular Autoimmune
Syndromes:
• Type I (APECED Syndrome)
– Mucocutaneous candidiasis, AD,
Hypoparathyroidism, 1 hypogonadism,
Malabsorption
• Type II (Schmidt’s syndrome)
– Primary adrenal insufficiency, Autoimmune
thyroid disease, Type I Diabetes