Adrenal insufficiency

Question 1

Causes of primary adrenal insufficiency

Answer 1

autoimmune
infections (TB, HIV, disseminated fungal)
hemorrhagic infarction
metastatic dx

Question 2

clinical presentation of adrenal insufficiency

Answer 2

fatigue, weakness, anorexia/weight loss, salt craving
GI symptoms
postural hypotension
hyperpigmentation or vitiligo
hyponatremia, hyperkalemia
may lead to acute adrenal crisis

Question 3

what is acute adrenal crisis?

Answer 3

abdominal pain, shock, fever AMS

Question 4

diagnosis of primary adrenal insufficiency?

Answer 4

Get ACTH, serum cortisol and high dose (250 ug) ACTH stimulation test

primary adrenal insufficiency: low cortisol and high ACTH

Question 5

labs seen on secondary or tertiary adrenal insufficiency

Answer 5

low cortisol and low ACTH

Question 6

labs seen on primary adrenal insufficiency:

Answer 6

low cortisol and high ACTH

Question 7

primary adrenal insufficiency is most commonly caused by:

what is it associated with?

Answer 7

seen with autoimmune adrenalitis or Addison’s dx
(90%) of pts

Seen with hypothyroidism or DM1

Question 8

fatigue and weight loss and non specific symptoms

Answer 8

initial symptoms of primary adrenal insufficiency:

Question 9

what happens to pts who have primary adrenal insufficiency and are acutely stressed (infection, major surgery)

Answer 9

develop adrenal crisis with abdominal pain, shock and AMS

Question 10

what are seen on labs with primary adrenal insufficiency:

Answer 10

non anion gap metabolic acidosis
hyponatremia- lacks mineralcorticoids
hypoglycemia - lacks glucocorticoid
hyperkalemia - lacks aldosterone

(elevated K only happens in 40% of pts)

can see high Ca but related to hemoconcentration and acute renal failure from hypovolumia

Question 11

what causes the hyperpigmentation in Addison’s dx?

Answer 11

secretion of ACTH leads to skin hyperpigmentation as concurrent melanocyte stimulating hormone is formed

Question 12

how to diagnose primary adrenal insufficiency:

Answer 12

get a 8 am serum coritsol, plasma ACTH and a ACTH stimulation (cosyntropin test)

Question 13

Treatment of adrenal insufficiency is with

Answer 13

hydrocortisone or steroid replacement.

Question 14

Primary adrenal insufficiency should be treated with

Answer 14

both fludrocortisone and hydrocortisone for the mineracorticoid deficiency and the glucorticorticoid deficiency

Question 15

secondary adrenal insufficiency (exogenous steroids) should be treated with

Answer 15

hydrocortisone only no need for fludrocortisone because there is no mineralcorticoid deficiency in secondary adrenal insufficiency.

Question 16

8 am serum cortisol <3 means

Answer 16

adrenal insufficiency

if value is >15-18 then it excludes the diagnosis as long as there are no binding protein abnormaltieis and synthetic glucocorticoid exposure is excluded.