Adrenal Insufficiency (addisons)

Question 1

What are the primary causes of adrenal insufficiency?
What are they?

Answer 1

Developed world = Addisons (80% in UK and developed countries)
Autoimmune destruction of adrenal gland, has skin pigmentation

Developing world = TB (+ sarcoidosis)
Infection spread from lungs to adrenals, inflammation and destruction

Question 2

What is the secondary cause of adrenal insufficiency?

Answer 2

Iatrogenic (suppression of HPA axis)
Caused by steroids

Question 3

Other causes?

Answer 3

Adrenal metastasis (lung, liver, breast)

Adrenal hemorrhage (eg. Meningococcal septicemia)

Question 4

Adrenal insufficiency due to adrenal hemorrhage is Called?
What’s the main cause of this?

Answer 4

Waterhouse frednchen syndrome
Meningococcal meningitis

Question 5

Pathophysiology of adrenal insufficiency

Answer 5

Destruction of adrenal cortex = decreased production of glucocorticoid (cortisol) and mineral corticoid (aldosterone)

Question 6

Which disease as pigmentation and why?

Answer 6

1^ = Addisons = destroyed adrenal cortex = decreased adrenal hormones but increased ACTH (from pituitary) overactive, increased ACTH stimulated propiomelancortin (POMC) = increased melanocytes stimulating hormone = hyperpigmentation

Question 7

Does 2^ have hyperpigmentation and why?

Answer 7

No
HPA suppression - decreased ACTH- decreased adrenal hormone = no hyperpigmentation

Question 8

Signs and symptoms of adrenal insufficiency?

Answer 8

Lethargy, fatigue, weight loss, hyperpigmentation (primary), postural hypotension (decreased aldosterone), vitiligo + change in body hair (low androgens), hypoglycemia, abdo pain and vomiting

Question 9

What is the gold standard way of diagnosing adrenal insufficiency ?

Answer 9

Short synACTHen test (ACTH stimulating test) - test adrenal reserve
1. Measure basal cortisol at 9am (cortisol normally highest-here, if low then very abnormal)

2. Administer synthetic ACTH
3. Sample cortisol again after 30 mins

If plasma cortisol >580 nmol/L after 30 mins, exclude Addisons

Question 10

What are other tests that can be done?

Answer 10

21 alpha hydroxylase adrenal autoantibodies in blood

Chest x ray for TB is suspected

Adrenal CT or MRI

Question 11

What is ACTH like in primary and secondary adrenal insufficiency at 9am?

Answer 11

High at 9am in 1^
Low in 2^

Question 12

Treatment for adrenal insufficiency?

Answer 12

Hydrocortisone (cortisol)
Fludrocortisone (aldosterone)

Question 13

If trauma/infection, what is administered?

Answer 13

Double dose of hydrocortisone (cortisol needed for stress response)

Question 14

What is adrenal crisis?
Symptoms?
Treatment?

Answer 14

Severe adrenal insufficiency especially hypocortisolemia
N+V, renal failure, LOC
Immediate hydrocortisone, IV saline, dextrose (if hypoglycemia)