Adrenal insufficiency Flashcards
What is primary adrenal insufficiency?
Destruction of the Adrenal leading to lack of Cortisol, Aldosterone, DHEAS.
Signs and symptoms of primary adrenal insufficiency as correlated to the hormone lacking
Decreased Cortisol: Hypoglycemia, Confusion, Weakness, Fatigue. Decreased Aldosterone: Hyponatremia & Hyperkalemia, Dehydration, Hypotension, Salt craving, Weakness, Abdominal pain, nausea, decreased appetite. Decreased DHEAS: Fatigue
General symptoms (repetitive) of adrenal insufficiency
Salt cravings “I love to drink the juice around the pickles”, Fatigue, Muscle weaknesss, Dizzyness, Nausea, Vomiting, Abdominal pain, “Sense of impending doom, feeling down”, Weight loss
General signs of symptoms of adrenal insufficiency
Postural drop in blood pressure, Postural increase in pulse, Weight loss, Abdominal tenderness, Muscle weakness, Hyperpigmentation of gum lines, palmar creases, and scars (Primary AI); Vitiligo (Primary AI)
Causes of primary adrenal insufficiency
Autoimmune: Poly Glandular Autoimmune I and II. Infections: TB, histoplasmosis, coccidiomycosis, cryptococcus, HIV, CMV, MAI, toxoplasma, Syphilis Metastatic Disease (lung, breast, stomach and colon cancer, lymphoma). Adrenal Hemorrhage (Waterhouse-Friderichsen Syndrome, Lupus anticoagulant, Anticoagulation). Drugs (interfere with cortisol synth): Metyrapone, Aminoglutethimide, Ketoconazole, Rifampin, Barbiturates, Phenytoin
Familial causes of adrenal insufficiency - most common in peds
Congenital Adrenal Hyperplasia, Adrenoleukodystrophy, Adrenomyeloneuropathy, Familial glucocorticoid deficiency, Familial glucocorticoid resistance, Defective cholesterol metabolism
APS Type 1
Single gene disorder. Aire is a TF in thymus, defect causes failure to delete auto reactive T cells - leads to autoimmunity. Associated with Hypoparathryoidism, Chronic Mucocutaneous Candidiasis (oral thrush), Adrenal Insufficiency
APS Type 2
More common, linked to HLA region of chromo 6. Associated with diabetes, addison’s (100%) and thyroid autoimmunity
What is Secondary adrenal insufficiency?
Same thing really. Caused by Prior history of steroid use - can be irreversible (need to taper off) - hypo and pituitary are impaired. Also caused by Pituitary Disease / Hypothalamic Disease, Isolated ACTH Deficiency, post transphenoidal pituitary surgery, Peripheral Resistance to glucocorticoids. Secondary is more common that primary insufficiency
How do we test for adrenal insufficiency?
Best is ACTH stimulation. baseline cortisol, ACTH - ACTH 250 ug IV push - cortisol at 1 hr, should double from its baseline in 1 hour and should be at least 550 nmol/L.
Primary vs secondary adrenal insufficiency
1 is low ACTH and low cortisol, low Na, high K, low glucose, hyperpigmentation. 2 is high ACTH and low cortisol, low Na (due to low cortisol, although aldosterone still there), normal K (aldosterone is stimulated by renin pathway), low glucose.
Adrenal crisis - what is it?
Weight Loss, Fatigue, Weakness, Severe Hypotension, Abdominal Symptoms
Tx for adrenal crisis
IV fluids, IV steroids, treat whatever precipitated it.
Long term management of addison’s
Medic alert bracelet. Glucocorticoids (prednisone, hydrocortisone, cortisone Acetate, Dexamethasone), Mineralocorticoids – Florinef (for 1 insufficiency). Pt needs to double the glucocorticoids during minor illness or stress (to make it like a normal response), IV steroids for major illness/surgery/hospitalization.
Complications of using glucocorticoids
Adrenal Suppression, Avascular Necrosis of the Hip, Cushing’s Syndrome, Diabetes, Hypertension, Obesity, Hypertriglyceridemia, Osteoporosis