Addison's

Question 1

Definition

Answer 1

A primary adrenal insufficiency caused by destruction of the adrenal cortex leading to deficiencies in cortisol, mineralocorticoids and sex hormones

Question 2

Aetiology

Answer 2

Autoimmune: 80% in the UK.
TB: most common cause worldwide. Overwhelming sepsis.
Metastatic cancer: lung/ breast. Lymphoma.
Adrenal Haemorrhage.
• Waterhouse-Friderichsen syndrome.

Question 3

Signs and Symptoms

Answer 3

Signs: postural hypotension, loss of body hair (pubic and axillary), pigmentation (new scars and palmer creases), dehydration
symptoms: Weight loss, malaise, weakness, myalgia. Syncope. Depression.

Addisonian crisis: Presents with fever, nausea & vomiting, shock, hypoglycaemia, hypernatremia and hypokalaemia.

Question 4

Pathophysiology

Answer 4

21-hydroxylase adrenal autoantibodies
TB
metastatic disease

Question 5

Risk factors

Answer 5

?

Question 6

Investigations

Answer 6

FBC: anaemia
Us and Es: low sodium, high potassium, uraemia
Raised calcium
Glucose low (bc of low cortisol)

Tests: Synacthen test/stimulate ACTH
Measure plasma cortisol before and 30 mins after
9am cortisol: raised ACTH but normal or low cortisol

CXR TB? Metastatic disease
ABs?

Question 7

Treatment

Answer 7

Long-term glucocorticoid cover;
• 15-2Smg hydrocortisone daily, in three divided doses.
• Avoid giving late in the day, as can cause insomnia.
Long-term mineralocorticoid cover;
• Required if postural hypotension, low sodium or high
potassium.
• Fludrocortisone 50-200 micrograms daily.
Steroids should never be abruptly stopped.
Extra doses should be given for strenuous exercise.
• Double the dose for surgery, febrile illness or trauma. Patient should have a ‘steroid card’/ bracelet, and carry IM hydrocortisone in case of Addisonian crisis.