Addisons

Question 1

Cause of addisons disease

Answer 1

Autoimmune destruction of the adrenal glands (80%)

Features
lethargy, weakness, anorexia, nausea & vomiting, weight loss, ‘salt-craving’
hyperpigmentation (especially palmar creases)*, vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia
hyponatraemia and hyperkalaemia may be seen
crisis: collapse, shock, pyrexia

Question 2

What two hormones have reduced production in addisons?

Answer 2

reduced cortisol and aldosterone

Question 3

Features of addisons

Answer 3

Lethargy
weakness
anorexia
nausea & vomiting
‘salt-craving’
hyperpigmentation (especially palmar creases)*
vitiligo
loss of pubic hair in women
hypotension
Low glucose, Na, K

crisis: collapse, shock, pyrexia

Question 4

Name other Primary causes of Hypoadrenalism

Answer 4

TB
Adrenal mets (lung ca)
Meningococcal septicaemia (Waterhouse-Friderichsen syndrome)
HIV
antiphospholipid syndrome

Question 5

Name some causes of secondary hypoadrenalism

Answer 5

pituitary disorders (e.g. tumours, irradiation, infiltration)

Exogenous steroids

Question 6

What is the main clinical difference between a patient presenting with Addisons vs Secondayr hypoadrenalism?

Answer 6

No increased skin pigmentation in secondary causes

Question 7

What investigation is the gold standard for diagnosis of addisons?

Answer 7

Short Synacthen test (ACTH stimulation)

Associated electrolyte abnormalities are seen in around one-third of undiagnosed patients:
hyperkalaemia
hyponatraemia
hypoglycaemia
metabolic acidosis

Question 8

Describe how to do a short synacthen test

Answer 8

Baseline measurement of Plasma cortisol

Give Synacthen

Measure cortisol 30 mins after Synacthen given

Question 9

If a random serum cortisol needs to be taken instead, ideally when should this be done?

Answer 9

9 am serum cortisol

> 500 = Addison’s very unlikely
< 100 = abnormal
100-500 = do Short Synacthen test to confirm

Question 10

What can precipitate addisonian crisis?

Answer 10

• sepsis
• surgery
• adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia)
• steroid withdrawal

Question 11

Management of Addisonian crisis

Answer 11

• hydrocortisone 100 mg im or iv then 6 hourly
• 1 litre saline infused over 30-60 mins or with dextrose if hypoglycaemic
• NO fludrocortisone required
• oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days