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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