Adrenal Insufficiency

Question 1

what is the definition of adrenal insufficiency

Answer 1

deficiency of adrenal cortical hormones (mineralocorticoids, glucocorticoids & androgens)

Question 2

what is the aetiology of adrenal insufficiency

Answer 2

primary (addison’s disease): autoimmune (>70%)

infections: TB, meningococcal septicaemia (waterhouse-friderichsen syndrome), CMV (HIV patients)
secondary: pituitary/hypothalamic disease
iatrogenic: sudden cessation of long term steroid therapy

Question 3

what is the epi of adrenal insufficiency

Answer 3

iatrogenic is most common cause

primary causes are rare (addison’s is 8/1,000,000PA)

Question 4

what is the history associated with adrenal insufficiency

Answer 4

chronic: non-specific vague symptoms (dizziness, anorexia, weight loss)
acute presentation (addisonian crisis): acute adrenal insufficiency with major haemodynamic collapse often precipitated by stress (infection/surgery)

Question 5

what are the examination findings associated with adrenal insufficiency

Answer 5

postural hypotension
increased pigmentation (generalised & more noticable on scars, skin creases, pressure points)
loss of body hair in women (androgen deficiency)
associated autoimmune conditions (vitiligo)
addisonian crisis (hypotensive shock, tachycardia, pale, cold, oligouria)

Question 6

what is the cause of increased pigmentation on pressure points in adrenal insufficiency

Answer 6

melanocytes stimulated by increased ACTH

Question 7

what investigations would be performed in suspected chronic adrenal insufficiency

Answer 7

to confirm the diagnosis
-9am serum cortisol <100nmol/l diagnostic
-9am serum cortisol >550nmol/l AI unlikely
-9am serum cortisol 100-550nmol/l short ACTH stimulation test (short synacthen test) - if serum cortisol <550nmol/l at 30mins, indicates adrenal failure
to identify the level of ACTH defect
-cortisol high in primary disease
-cortisol low in secondary disease
-long synacthen test (patients with primary AI show no increase after 6 hours)

Question 8

what would be given in a short synacthen test?

Answer 8

IM 250microgram tetracosactrin (synthetic ACTH)

Question 9

what investigations would be performed in suspected acute adrenal insufficiency

Answer 9

addisonian crisis
FBC (neutrophilia)
UEs (high urea, low Na, high K)
ESR/CRP raised in acute infection
low glucose

Question 10

what is the management for acute adrenal insufficiency (addisonian crisis)

Answer 10

rapid IV fluid rehydration (0.9% saline, 1l over 30-60min, 2-4l over 12-24h)
50ml of 50% dextrose to correct hypoglycaemia
IV 200mg hydrocortisone bolus followed by 100mg 6 hourly until BP is stable
treat cause & monitor temperature, pulse, BP, RR

Question 11

what is the management for chronic adrenal insufficiency

Answer 11

replacement of glucocorticoids with hydrocortisone (increased in illness/stress) (3xD)
replacement of mineralocorticoids with fludrocortisone
with hypothyroidism, give hydrocortisone before thyroxine to avoid addisonian crisis

Question 12

what are the complications associated with adrenal insuffieciency

Answer 12

hyperkalaemia

death during addisonian crisis

Question 13

what is the prognosis associated with adrenal insufficiency

Answer 13

adrenal function rarely recovers BUT normal life expectancy if treated
T1 (autosomal recessive disorder by mutation in AIRE gene which encodes nuclear transcription factor): Addison’s disease, hypoparathyroidism
T2 (Schmidt’s syndrome): Addison’s disease T1DM, hypothyroidism, hypogonadism)