adrenal insufficiency

Question 1

define adrenal insufficiency?

Answer 1

destruction of entire adrenal cortex -> reduced production of sex steroid, glucocorticoids, and mineralocorticoids

Question 2

causes of adrenal insufficiency?

Answer 2

primary (addison disease)
-autoimmune disease (most common)
-infectious: tuberculosis
-hemorrhagic: sepsis, DIC
-infiltrative: metastasis, amyloid

secondary
-sudden discontinuation of steroid therapy
-hypopituitarism

tertiary
-sudden discontinuation of steroid therapy
-hypothalamic dx

Question 3

symptoms?

Answer 3

-low aldosterone (only in primary cases): hyponatremia, hyperkalemia, hypotension, metabolic acidosis

low glucocorticoid: hypoglycemia, GI complaints (N/V), orthostatic hypotension, fatigue

hypoandrogen: loss of libido

high ACTH (only in primary): ACTH stimulates melanocyte stimulating hormone -> pigmentation of palmer creases and mucus membrane of oral cavity

primary causes pigmentations, secondary spares the skin, tertiary due to treatment

Question 4

diagnosis?

Answer 4

ACTH stimulation test (cosyntropin) then measure cortisol
primary: low
secondary: low but may increase after a while

ACTH level
primary: high
secondary: low

plasma renin: low in primary due to hypoaldosteronism, CT brain to look at pituitary, CT adrenals looks for calcifications if TB or CXR, 21 hydroxylase antibodies if autoimmune

Question 5

long term management and adrenal crisis management?

Answer 5

long term management:
primary -> daily oral corticosteroid and mineralocorticoid (fludrocortisone)
secondary: only steroid needed since aldosterone is normal

adrenal crisis due to stress or discontinuing tx -> severe hypotension and shock and abdomen pain
give IV normal saline and IV glucocorticoid until pt is stabilized. if hypoglycemic give IV dextrose