Primary Adrenal Insufficiency
Addison's Disease - Damage of the adrenal glands with lack of cortisol, androgens and aldosterone
Causes of Adrenal Insufficiency:
Most Common Causes:
• Autoimmune > Tuberculosis
Infiltrative Disorders:
• Infection (tuberculosis, fungal infections)
- Tuberculosis: can cause adrenal calcification and enlargement
• Sarcoidosis
• Lymphoma
Metastatic Disease -> Adrenals:
• Lung cancer
• Renal cell carcinoma, and melanoma
Bilateral Adrenal Hemorrhage:
• Consider if unexpected hypotension develops
• Risk factors for BAH include protein C deficiency, anticoagulation, DIC and sepsis
- (Neisseria meningitidis, H Flu, pneumococci, pseudomonas)
Autoimmune: + 21-Hydroxylase Antibodies:
• 50% will develop another autoimmune endocrine disorder
- Primary hypothyroidism
- Primary ovarian insufficiency
- Celiac disease,
- Hypoparathyroidism
- Type 1 diabetes mellitus
Aldosterone Deficiency:
Symptoms:
• Salt craving
• Dizziness
• Nausea/vomiting
• Fatigue
Signs:
• Orthostasis
• Hypotension
Labs:
• ↑ PRA
• ↓ Serum sodium
• ↑ Serum potassium
• ↑ H+ (NAGMA from RTA type IV)
Cortisol Deficiency:
Symptoms:
• Fatigue
• Weakness
• Low-grade fever
• Weight loss
• Anorexia
• Nausea/vomiting
• Abdominal pain
• Back pain
• Arthralgia
• Myalgia
Cortisol Deficiency: Signs
• Hyperpigmentation ("bronzing")
- Palmar creases
- Extensor surfaces
- Buccal mucosa
- *Not present in approximately 5% patients
• ↓ BP
• ↓ Serum cortisol
• ↑ Plasma ACTH
• ↓ Serum sodium
• ↓ Plasma glucose
• ↑ Eosinophils (Not always present)
↓ DHEA/Androgens:
• Symptoms: Reduced libido
• Signs: Decreased axillary or pubic hair
• Labs: ↓ Serum DHEAS
Diagnosis:
• History and physical:
- Symptoms/physical exam.
- Dark patches on the skin might be a clue
• Blood tests:
- Check sodium, potassium, AM cortisol and ACTH
- + 21-hydroxylase antibodies are found in approximately 90% of autoimmune adrenalitis cases
- Serum cortisol < 3 ug/dL -> Primary AI present
- ACTH stimulation test: Administer 250 mcg ACTH. Measure at 0, 30, and 60 mins.
- Check Serum Cortisol. IF < 18 ug/dL Primary AI present
- ACTH test is not affected by use of DEXAMETHASONE
- ACTH test is affected by HYDROCORTISONE
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