Adrenal insufficiency Flashcards
outline the typical presentation of adrenal insufficiency?
Increased pigmentation, postural hypotension, fatigue, weakness, myalgia, D+V
define adrenal insufficiency?
Deficiency of adrenal cortical hormones (e.g. mineralocorticoids, glucocorticoids and androgens)
outline the aetiology
Primary Adrenal Insufficiency
- Addison’s disease(usually autoimmune or TB)
Secondary Adrenal Insufficiency
- Pituitary or hypothalamic disease(could be caused by steroids as will suppress ACTH and cause atrophy)
- ACTH would be low in this situation
Infections
- Tuberculosis
- Meningococcal septicaemia (Waterhouse-Friderichsen Syndrome)
- Adrenal hemorrhage=> abdo pain, fatigue, weakness, dizziness, V
- CMV
- Histoplasmosis
Infiltration
- Metastasis(mainly from lung, breast, melanoma)
- Lymphomas
- Amyloidosis
Infarction
- Secondary to thrombophilia
Inherited
- Adrenoleukodystrophy
- ACTH receptor mutation
Surgical
- After bilateral adrenalectomy
Iatrogenic
- Sudden cessation of long-term steroid therapy
what are the presenting symptoms of adrenal insufficiency ?
- Dizziness
- Anorexia
- Weight loss
- Diarrhoea and Vomiting
- Abdominal pain
- Lethargy
- Weakness
- Depression
outline the acute presentation of adrenal insufficiency?
ADDISONIAN CRISIS
Acute adrenal insufficiency
Major haemodynamic collapse: shock, N+V, hypothermia and abdo pain
Precipitated by stress (e.g. infection, surgery)
what are the signs of adrenal insufficiency on physical examination ?
- Postural hypotension
- Increased pigmentation- More noticeable on buccal mucosa, scars, skin creases, nails and pressure points
- Loss of body hair in women(due to androgen deficiency)
- Associated autoimmune condition (e.g. vitiligo)
Addisonian Crisis Signs
- Hypotensive shock
- Tachycardia
- Pale
- Cold
- Clammy
- Oliguria
what are the investigations done in an addisonian crisis?
FBC (neutrophilia –> infection)
U&Es
- High urea
- Low sodium
- High potassium
- High calcium
CRP/ESR
Glucose - low
Blood cultures
Urinalysis
Culture and sensitivity
what are the other tests used to find the cause of adrenal insufficinecy
Autoantibodies (against 21-hydroxylase)
Abdominal CT or MRI
Other tests (adrenal biopsy, culture, PCR)
what are the tests that can be used to confirm the diagnosis of adrenal insufficiency?
9 am Serum Cortisol (< 100 nmol/L is diagnostic of adrenal insufficiency)
Random cortisol > 550 nmol/L makes adrenal insufficiency unlikely
If ACTH levels are raised, it indicates primary insufficiency vs low levels indicating secondary insufficiency
describe the short synacthen and long synacthen tests for adrenal insufficiency?
Short Synacthen Test
- Give IM 250 µg tetrocosactrin (synthetic ACTH)
- Serum cortisol < 550 nmol/L at 30 mins indicates adrenal failure
- Identify the level of the defect in the hypothalamo-pituitary-adrenal axis
Long Synacthen Test
- 1 mg synthetic ACTH administered
- Measure serum cortisol at 0, 30, 60, 90 and 120 minutes
- Then measure again at 4, 6, 8, 12 and 24 hours
- Patients with primary adrenal insufficiency show no increased after 6 hours
describe the management for an addisonian crisis?
- Rapid IV fluid rehydration
- 50 mL of 5% dextrose to correct hypoglycaemia
- IV or Im 100 mg hydrocortisone bolus
- Followed by 100 mg 6 hourly hydrocortisone until BP is stable
- Treat precipitating cause (e.g. antibiotics for infection)
- Monitor
describe the management for chronic adrenal insufficiency?
repacement of:
Glucocorticoids with hydrocortisone (3/day)
Mineralocorticoids with fludrocortisone
Hydrocortisone dosage needs to be increased during times of acute illness or stress
NOTE: if the patient also has hypothyroidism, give hydrocortisone BEFORE thyroxine (to prevent precipitating an Addisonian crisis)
what advice should be given to patients with adrenal insufficiency?
Have a steroid warning card
Wear a medic-alert bracelet
Emergency hydrocortisone on hand
what are the complications of adrenal insufficiency?
HYPERKALAEMIA– due to hypoaldosteronism (aldosterone is important in potassium excretion)
Death during Addisonian crisis
Osteopenia/osteoporosis
