adrenal%20insufficiency
ADRENAL INSUFFICIENCY
Adrenal insufficiency (AI) is the insufficient secretions of corticosteroids that may cause partial or complete destruction of the adrenal glands.
Primary AI or Addison’s disease is due to the inability of the adrenal gland to produce steroid hormones even when the stimulus by the pituitary gland via corticotrophin is adequate or increased.
Secondary AI is due to disorders of the pituitary gland that causes production of low levels of adrenocorticotropic hormone that will result to reduced cortisol levels.
Tertiary AI is the inability of the hypothalamus to produce sufficient amount of corticotropin releasing hormone.
Signs and symptoms are usually nonspecific with insidious onset.
Common signs and symptoms are fatigue, weakness, salt craving, orthostatic hypotension, nausea, vomiting, abdominal pain, diarrhea, anorexia and weight loss.

Definition

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

Types of Adrenal Insufficiency (AI)

  • Primary adrenal insufficiency (AI) or Addison’s disease is due to the inability of the adrenal gland to produce steroid hormones even when the stimulus by the pituitary gland via corticotropin is adequate or increased
  • Secondary AI is due to disorders of the pituitary gland that causes production of low levels of adrenocorticotropic hormone that will result to reduced cortisol levels 
    • Occurs in patients receiving chronic exogenous glucocorticoid treatment (≥5 mg Prednisolone or equivalent for ≥4 weeks) or chronic glucocorticoid cream or inhaler application or long-lasting glucocorticoid injections into joints
  • Tertiary AI is the inability of the hypothalamus to produce sufficient amount of corticotropin releasing hormone

Etiology

  • 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 & 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)

Signs and Symptoms

  • Usually nonspecific with insidious onset 

Primary Adrenal Insufficiency (AI):

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

Secondary & 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 & Tertiary Adrenal Insufficiency (AI):

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

Signs & Symptoms of Acute Adrenal Insufficiency (AI)

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

Signs & 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/vomiting
  • Metabolic acidosis
  • Abdominal pain
Patient with underlying chronic adrenal insufficiency (AI) who presents in crisis may show common symptoms of adrenal insufficiency (AI)
  • Hyperpigmentation
  • Vitiligo
  • Sparse pubic and axillary hair
  • Hyponatremia or hyperkalemia
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