Adrenal%20insufficiency Signs and Symptoms

• Adrenal insufficiency (AI) is the inability of the adrenal gland to produce sufficient adrenocortical steroid hormones

• Rapid withdrawal of steroids in patients with adrenal atrophy due to chronic steroid therapy
  • Most common cause of acute adrenal insufficiency (AI)
• Rapid intensification of chronic primary adrenal insufficiency caused by sepsis or acute major stress
• May occur in patients receiving glucocorticoids if mineralocorticoid requirements are not met
• Rare in patients with secondary or tertiary adrenal insufficiency
• Destruction of both adrenal glands caused by acute hemorrhage
  • In children, may be caused by septicemia
  • In adults, may be caused by anticoagulant therapy or a coagulation disorder

• Patients with congenital adrenal hyperplasia who are given drugs that inhibit steroid synthesis or increase steroid metabolism

Primary Adrenal Insufficiency (AI)

• Progressive destruction of the adrenals which is most commonly caused by idiopathic atrophy (probably autoimmune in nature), tuberculosis (TB), fungal infections, adrenal hemorrhage, acquired immune deficiency syndrome (AIDS), etc
• May also be caused by insufficient hormone production caused by congenital adrenal hyperplasia, enzyme inhibitors (eg Metyrapone), or cytotoxic agents (eg Mitotane), adrenal surgery

Secondary and Tertiary Adrenal Insufficiency (AI)

• Pituitary or hypothalamic disorders
• Suppression of the hypothalamic-pituitary axis by exogenous steroid (ie long-term glucocorticoid therapy) or endogenous steroid (eg tumor)
  • Exogenous glucocorticoid doses of 5 mg or higher Prednisolone or equivalent for >4 weeks either inhaled, injected, oral or topical, is the most common cause of drug-induced adrenal insufficiency

• Usually nonspecific with insidious onset 

Primary Adrenal Insufficiency (AI):

• Hyperpigmentation - most characteristic
• Hyperkalemia, hyponatremia
• Autoimmune thyroid disease
• Vitiligo

Secondary and Tertiary Adrenal Insufficiency (AI):

• Manifestations usually begin in the first 48 hours after steroid medication has been discontinued 
• Similar to primary AI except that hyperpigmentation and dehydration are absent; gastrointestinal (GI) symptoms and hypotension are less prominent
• Hyponatremia and volume expansion may be present
• Hypoglycemia is more commonly seen than in primary AI
• Pale skin without significant anemia
• Prepubertal growth deficiency, delayed puberty
• May present with clinical manifestations of pituitary or hypothalamic tumor, eg diabetes insipidus (DI)
• Secondary hypothyroidism
• Decreased libido and potency, amenorrhea
• Visual symptoms, headache

Primary, Secondary and Tertiary Adrenal Insufficiency (AI):

• Fatigue
• Weakness
• Salt craving
• Orthostatic hypotension, dizziness, hypovolemic shock
• Nausea and vomiting (N/V); abdominal pain, tenderness and guarding
• Fever
• Diarrhea
• Anorexia, weight loss
• Confusion, somnolence
• In severe cases, delirium or coma

• Acute adrenal insufficiency (AI) or adrenal crisis usually occurs with concomitant injury or illness and is difficult to diagnose

Signs and symptoms may be non-specific 

• Shock or unexplained catecholamine-resistant hypotension is the most predominant manifestation
• Fatigue
• Diarrhea
• Weakness
• Lethargy
• Fever
• Confusion
• Coma
• Anorexia
• Nausea and vomiting
• Metabolic acidosis
• Abdominal pain

• Hyperpigmentation
• Vitiligo
• Sparse pubic and axillary hair
• Hyponatremia or hyperkalemia