Adrenal insufficiency ( Hypoadrenalism )
Acute or chronic -acute onset – Adrenal crisis ( life threatening ) chronic – can be more difficult to diagnose as presentation can be non-specific and vague hyperpigmentation may not always be present exogenous administration of glucocorticoids is the most common cause of adrenal insufficiency in clinical practice during critical illnesses – functional or relative adrenal insufficiency can be seen
Evaluation – presentation can be with hypotension , altered mental status , anorexia , vomiting , weight loss , fatigue , recurrent abdominal pain in women 0 amenorrhoea , loss of libido , ↓ axillary / pubic hair poor skin turgor , ↑ skin pigmentation consider checking serum cortisol , ACTH , renin , aldosterone and Us&Es ↓ Na , ↑ K , ↓ bl glucose may be present Short ACTH stimulation test should be considered
Level of defect –
Primary- Pathology affects the adrenal gland itself diminished gland function acute presentation can be with adrenal crisis and chronic with Addison’s disease most common cause of adrenal insufficiency / Addison’s disease is autoimmune destruction of the adrenal cortex other causes include haemorrhage , cancer , infections ( as HIV , syphilis , tuberculosis ) and drugs as ketoconazole , fluconazole autoimmune destruction can be isolated or in the context of autoimmune polyendocrinopathy TB was the most common cause before the advent of antibiotic ( before 1960s ) for 1ary insufficiency
Secondary- Decreased ACTH secretion from pituitary any disease process that affects the anterior pituitary interfering with ACTH secretion aldosterone levels are not affected traumatic brain injury and panhypopituitarism are common causes.
Tertiary- Decreased hypothalamic stimulation of the pituitary to secrete ACTH ( abrupt cessation of exogenous steroid administration -leading to suppression of the HPA axis , surgery to correct Cushing’s disease are common causes )
REFERENCES
- Diagnosis of adrenal insufficiency in adults UpToDate https://www.uptodate.com/contents/diagnosis-of-adrenal-insufficiency-in-adults?search=hypoadrenalism&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
- Huecker MR, Bhutta BS, Dominique E. Adrenal Insufficiency. [Updated 2022 Mar 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441832/
- Nicolaides NC, Chrousos GP, Charmandari E. Adrenal Insufficiency. [Updated 2017 Oct 14]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279083/
