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disorders
Steroid actions
Amino acid catabolism (muscle wasting)…
gluconeogenesis in the liver.. Hyperglycemia… increased
insulin output… eventual beta cell failure… fat
deposition… diabetes
Ca resorption, impairment of Ca absorbtion, increased
renal Ca excretion…. osteoporosis
Increased gastric acidity… ulcer formation or aggravation
K loss and Na retention… edema and hypertension
Initially increased antibody release.. Eventually decreased
antibody production, lymphocytopenia, eosinopenia,
neutrophelia, polycythemia… susceptibility to infections
Maintenance of arteriolar tone and blood pressure
Adrenal Insufficiency
Causes of Adrenal
Insufficiency
Primary
Idiopathic (Addison disease)
Tuberculosis
Fungal infections
Adrenal hemorrhage
Sarcoidosis
Amyloidosis
Metastatic neoplasia
Others
Causes of Adrenal
Insufficiency
Secondary
After exogenous glucocorticoids
(removing endogenous
glucocorticoids)
Hypothalamic and pituitary lesions
Major Clinical Features in Adrenal
Insufficiency
Weakness
Skin
Mucous membrane and skin pigmentation,
Confirmation
Establishing Etiology
Morning cortisol levels are a good screening test to rule out adrenal
insufficiency and levels above 20 mcg/dL are considered normal. Lower values
are not diagnostic of disease, but require further evaluation.
Steroid cell antibodies (Adrenal Total Abs) : 70% of patients with autoimmune
adrenalitis, are helpful in the differential diagnosis of tuberculous adrenalitis.
Standard Plasma
Consyntropin ACTH
Stim Test Level
50
-
40
-
20
-
5- Primary Secondary
Pre 60’ post Pre 60 ‘ post
3-
>18 - 20 mcg/dL 60” post : +
Etiology of Adrenal Insufficiency
Primary
Secondary
Autoimmune
-Pituitary Tumor
Metastatic
-Vascular
TB
Fungal
MRI
AIDS
Sella
CT
Adrenals
Etiology of Addison’s Disease
CT adrenals
Small
Unenlarged
Enlarged
Autoimmune Biopsy
Acute Adrenal Crisis
Adrenal Decompensation
Fatal if untreated
or excluded later
Adrenal Crisis
Rapid evolution
Nausea Hyponatremia
Vomiting Hyperkalemia
Abdominal Pain Hypoglycemia
Dizziness
Hypotension Hyperuricemia
Dehydration pre renal azotemia
Lethargy Eosinophilia
Muscle stiffness Natriuresis
Cardiac arrythmia
Shock
Adrenal Crisis
Treat as emergency
IV NaCl 0,9 %
IV hydrocortisone 100
mg tid
Hydrocortisone 20 mg =Dexamethasone 0.75 mg = Prednisone 5 mg =Prednisolone 4 mg
A 62 year old man seen in the MICU
Admitted for pneumonia and hypoxia.
On a ventilator.