Adrenal insufficiency

Question 1

Primary Adrenal Insufficiency: Addison’s - what is it

Answer 1

Destruction of adrenal cortex → glucocorticoid and mineralocorticoid deficiency

Question 2

Causes of Addison’s

Answer 2

Autoimmune destruction: 80% in the UK
  TB: commonest worldwide
  Metastasis: lung, breast, kidneys
  Haemorrhage: Waterhouse-Friedrichson
  Congenital: CAH

Question 3

Symptoms

Answer 3

Wt. loss + anorexia
  n/v, abdo pain, diarrhoea/constipation
  Lethargy, depression
  Hyperpigmentation: buccal mucosa, palmer creases
  Postural hypotension → dizziness, faints
  Hypoglycaemia
  Vitiligo
  Addisonian crisis

Question 4

Investigations - bloods

Answer 4

↓Na/↑K ↓glucose ↓Ca

Anaemia

Question 5

Differential Ix

Answer 5

Differential
Short synACTHen test
Cortisol before and after tetracosactide
Exclude Addison’s if ↑ cortisol ↑ 9am ACTH (usually low)

Question 6

Other Ix

Answer 6

Other
21-hydroxylase Abs: +ve in 80% of AI disease Plasma renin and aldosterone
CXR: evidence of TB
AXR: adrenal calcification

Question 7

Treatment (3)

Answer 7

Replace
Advice
Follow up

Question 8

Replace

Answer 8

Hydrocortisone

Fludrocortisone

Question 9

Advice

Answer 9

Don’t stop steroids suddenly
↑ steroids during intercurrent illness, injury
Wear a medic-alert bracelet
Need PPI if taking with NSAIDS

Question 10

Follow up

Answer 10

Watch for autoimmune disease

Question 11

Secondary adrenal insufficiency - causes

Answer 11

i.e. hypothalamo or pituitary failure

Chronic steroid use → suppression of HPA axis
Pituitary apoplexy / Sheehan’s
Pituitary microadenoma

Question 12

Features of secondary adrenal insufficiency

Answer 12

Normal mineralocorticoid production   
No pigmentation (ACTH ↓)

Question 13

Addisonian Crisis presentations

Answer 13

Shocked: ↑HR, postural drop, oliguria, confused Hypoglycaemia
Usually known Addisonian or chronic steroid user

Question 14

Precipitants

Answer 14

Infection
Trauma
Surgery
Stopping long-term steroids

Question 15

Management

Answer 15

Bloods: cortisol, ACTH, U+E, cultures
  Check CBG: glucose may be needed
  Hydrocortisone 100mg IV 6hrly
  IV crystalloid
  Septic screen
  Treat underlying cause