Adrenal Insufficiency Flashcards
General Considerations of Adrenalcortical Insufficiency (AI)
aka Addison’s disease
Can be chronic or acute
Chronic has incidence of ~140 per million and ~4 per million in US
Acute often undiagnosed and untreated mimics more common conditions
Causes of Chronic AI (Addison’s Dz)
Autoimmune May also be assoc. w/ : Autoimmune thyroid disease Hypoparathyroid Type I DM Vitiligo Alopecia areata Celiac sprue Primary ovarian/testicular failure Pernicious anemia
Uncommon causes: TB, lymphoma, metastatic carcinoma, some infections
Symptoms of AI (Addison’s Dz)
Weakness, fatigability, anorexia, weight loss; nausea and vomiting, diarrhea; abdominal pain, muscle and joint pains; amenorrhea.
Sparse axillary hair; increased skin pigmentation, especially of creases, pressure areas, and nipples.
Hypotension, small heart.
Serum sodium may be low; potassium, calcium, and BUN may be elevated; neutropenia, mild anemia, eosinophilia, and relative lymphocytosis may be present.
Plasma cortisol levels are low or fail to rise after administration of corticotropin.
Plasma ACTH level is elevated.
Adrenal Crisis
Extreme adrenal insufficiency Profound fatigue Dehydration Vascular collapse (hypotension) Renal shutdown - low serum Na, high serum K
Addison’s - DD by Symptom
Hypotension - meds, hypovolemia, cardiogenic
Hyperkalemia - CKD, meds: ACE-I’s, spironolactone
Hyponatremia - Hypothyroidism, duretic use, liver disease, heart failure
Abdominal pain - GI causes, liver, gallbladder, pancreas
Hyperpigmentation - Hemochromatosis, normal race variation
Wt loss - CA, anorexia
Fatigue - hypothyroid, anemia
Addison’s imaging
Chest radiograph
The chest radiogram may be normal but often reveals a small heart.
Stigmata of earlier infection or current evidence of TB or fungal infection may be present when this is the cause of Addison disease.
CT scan
Abdominal CT scan may be normal but may show bilateral enlargement of the adrenal glands in patients with Addison disease because of TB, fungal infections, adrenal hemorrhage, or infiltrating diseases involving the adrenal glands.
If cause TB or histoplasmosis, evidence of calcification involving both adrenal glands may be present.
In idiopathic autoimmune Addison disease, the adrenal glands usually are atrophic.
Addison’s Lab Studies and Results
Tests: Serum electrolytes BUN & Creatinine Serum glucose Serum cortisol and serum ACTH ACTH stimulation test
Results: High potassium & BUN Low sodium & glucose Low cortisol level Elevated serum ACTH
ACTH Stimulating Test
Baseline aldosterone & cortisol levels drawn
Synthetic ACTH given IM or IV
30 mins after ACTH injection, blood drawn
Two criteria necessary for diagnosis:
An increase in baseline cortisol of >7mcg/dL
Value must rise to >20 mcg/dL in 30 or 60 min
Increase in aldosterone levels at 30 mins
A normal ACTH test excludes Addison (AI) but not secondary adrenal insufficiency such as hypothalamic-pituitary-adrenal axis impairment
Addison’s Management and Tx
Endo referral
Hormone replacement
Glucocorticoid: cortisone or hydrocortisone
Mineralocorticoid: fludrocortisone, prednisone
Dosages adjusted until no symptoms
Long term steroid replacement given to mimic the circadian rhythm pattern of cortisol secretion
Medic Alert Identification
Emergency Kit- syringe, needle with 4mg of dexamethasone
Addison’s Pt Education
treat all infections immediately and vigorously
Addison’s Prognosis
Most live fully active lives
Normal life expectancy w/treatment
Lack of treatment for acute leads to shock that is unresponsive to volume replacement & vasopressors, resulting in death
Acute AI
Presentation: Hypotension (postural) Tachycardia Dehydration Hyponatremia Hyperkalemia Hypoglycemia Fever Weakness Confusion Hypotension may lead to shock Immediate referral to ER if suspected
