Addisons Flashcards
Name some symptoms associated with addisons
Fatigue
Abdominal pain
Nausea vomiting
Postural dizziness
Low mood
Poor appetite
Weight loss
Menstrual disturbance
What skin changes do you get with addisons?
ACTH causes melanocyte stimulation - this causes dark patches in creases of hands, buccal mucosa
ACTH is high as its trying to feedback to the adrenals to produce steroid
What is important to ask in travel history?
TB exposure
Causes of hypoadrenalism
Primary -
Autoimmune adrenalitis (addisons disease)
TB related hypoadrenalism/HIV ALSO
Post meningococcal (Waterhouse -freidrichsein)
Mets from cancer
Infiltrative causes e.g. sarcoidosis/amyloidosis
Congenital adrenal hyperplasia
Secondary
- Exogenous steroids - the steroids stop the pituitary producing ACTH
- pituitary adrenoma
What would you examine in a patient where you suspect hypoadrenalism?
Inspect - Do they look unwell
Hands
- Palmar creases for dark pigmentation
-Any signs of vitiligo
Pulse - HR
Tremor - hands outstretched
BP - L/S
Myopathy
Face
- Visual fields
- Mouth for pigmentation
Abdomen
- Adrenalectomy scars
Investigations for addisons
Early morning cortisol (should be raised in normal people)
If acutely unwell a random cortisol should be ok as with being so unwell their cortisol should be raised (Therefore a low cortisol indicates likely hypoadrenalism)
SHORT SYNACTHEN
AND ACTH
Other tests to send:
Prolactin - raised in prolactinoma
Pituitary screen - LH/FSH may be low in pituitary failure
Bone profile due to hypoparathyroidism in autoimmune syndrome T1
ADRENAL AUTOANTIBODIES - anti- 21hydroxylase
How do you perform a short synacthen?
Measure baseline cortisol
Given Synthetic ACTH
Measure cortisol at 30 mins and 60 mins
FAILURE OF RISE IN CORTISOL INDICATES ADDISONS
Why do we check ACTH level
In primary adrenal insufficiency - ACTH should be raised
In secondary adrenal insuff - ACTH will be low
Also should check renin and aldosterone to assess mineralocorticoid activity (low aldosterone, high renin) - aldosterone is secreted by the adrenal glands
What other bloods should be done in addisons?
FBC - eosinophilia
RP - hyponatraemia and hyperkalaemia
BM - low glucose
HbA1c
Pituitary profile - LSH/FS/Testosterone/TSH/
What imaging is done in Addisons?
MRI adrenals
Treatment of patients who are acutely unwell with addisons?
IV Fluids with electrolyte
Glucose replacement
IV Steroids - 100mg QDS
Treatment of chronic adrenal insufficiency
Oral steroids Hydrocortisone (20mg OM, 10mg evening) and fludrocortisone
Patient education - bracelet, double steroid dose on unwell days
What are the polyglandular autoimmune syndromes?
T1: Immunodef, hypoparathyroidism, addisons
T2: Addisons, T1DM, hypo or hyperthyroidism
What should patients do when sick?
Double steroid doses
If vomiting, they should all have IM steroids to give and this should be given if unable to tolerate things orally
Name some autoimmune disorders associated with addisons
Vitiligo
Pernicious anaemia
Autoimmune thyroid disease
Diabetes
Rheumatoid arthritis
SLE
Sjogrens
What level of early morning cortsiol is suggestive of adrenal insuffiency?
<100 is indicative of adrenal insufficiency
What result would indicate, from a SST, adrenal insufficiency
If the cortisol level fails to go above 500
