Adrenal Insufficiency Flashcards
What is Adrenal Insufficiency?
Deficiency of adrenal cortical hormones
What are some examples of adrenal cortical hormones?
Mineralocorticoids
Glucocorticoids
Androgens
What are some of the causes and risk factors of adrenal insufficiency?
Primary Adrenal Insufficiency
Secondary Adrenal Insufficiency
Infections
Infiltration
Infarction
Inherited
Surgical
Iatrogenic
What are some examples of a Primary Adrenal Insufficiency?
Addison’s Disease (usually autoimmune)
What are some examples of Secondary Adrenal Insufficiency?
Pituitary or Hypothalamic Disease
What are some examples of infections?
Tuberculosis
Meningococcal septicaemia (Waterhouse-Friderichsen Syndrome)
CMV
Histoplasmosis
What are some examples of Infiltration?
Metastasis (mainly from lung, breast, melanoma)
Lymphomas
Amyloidosis
What is an example of an Infarction cause of adrenal insufficiency?
Secondary to thrombophilia
What is an inherited cause of Adrenal Insuffiency?
Adrenoleukodystrophy
ACTH receptor mutation
What is a surgical cause of Adrenal Insuffiency?
After bilateral adrenalectomy
What is the Iatrogenic cause of adrenal insuffiency?
Sudden cessation of long term steroid therapy
What is the epidemiology of adrenal insufficiency?
Most common cause is IATROGENIC
Primary causes are rare
What is the chronic presentation of adrenal insufficiency?
Dizziness
Anorexia
Weight Loss
Diarrhoea and Vomiting
Abdominal Pain
Lethargy
Weakness
Depression
What is the acute presentation of adrenal insufficiency (Addisonian Crisis)?
Acute Adrenal Insufficiency
Major Haemodynamic Collapse
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)
What are the signs of Addisonian Crisis?
Hypotensive Shock
Tachycardia
Pale
Cold
Clammy
Oliguria
What are some of the investigations for adrenal insufficiency?
To confirm the diagnosis
Identify the level of the defect in the hypothalamo-pituitary-adrenal axis
Identify the Cause
Check TFTs
How do you confirm the diagnosis for adrenal insufficiency?
- 9 am Serum Cortisol (< 100 nmol/L is diagnostic of adrenal insufficiency)
- >550 nmol/L makes adrenal insufficiency unlikely
- Short Synacthen Test
- IM 250 µg tetrocosactrin (synthetic ACTH)
- Serum cortisol < 550nmol/L at 30 mins indicates adrenal failure
How do you identify the level of the defect in the hypothalamo-pituitary-adrenal axis?
- HIGH in primary disease
- LOW in secondary
- 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
How do you identify the cause of adrenal insufficiency?
Autoantibodies (against 21-hydroxylase)
Abdominal CT or MRI
Other tests (adrenal biopsy, culture, PCR)
What investigations would you do for Addisoninan Crisis?
- FBC (neutrophilia –> infection)
- U&Es
- High Urea
- Low Sodium
- High Potassium
- CRP/ESR
- Calcium (may be raised)
- Glucose - low
- Blood Cultures
- Urinalysis
- Culture and Sensitivity
What is the management plan for adrenal insufficiency?
Rapid IV fluid rehydration
50 mL of 50% dextrose to correct hypoglycaemia
IV 200 mg hydrocortisone bolus
Followed by 100 mg 6 hourly hydrocortisone until BP is stable
Treat precipitating cause (e.g. antibiotics for infection)
Monitor
What is the management for Chronic Adrenal Insufficiency?
- Replacement of:
- Glucocorticoids with hydrocortisone (3/day)
- Mineralocorticoids with fludrocortisone
- Hydrocortisone dosage needs to be increased during times of acute illness or stress
- If the patient also has hypothyroidism, give hydrocortisone BEFORE thyroxine
What advice can you get for adrenal insufficiency?
Have a steroid warning card
Wear a medic-alert bracelet
Emergency Hydrocortisone on hand
What are the possible complications of adrenal insufficiency?
Hyperkalaemia
Death during Addisonian Crisis
What is the prognosis for patients with adrenal insufficiency?
Adrenal function rarely recovers
Normal life expectancy if treated
What is Autoimmune Polyendocrine Syndrome?
Type 1 - autosomal recessive disorder caused by mutations in the AIRE gene
Consists of the following diseases:
- Addison’s Disease
- Chronic Mucocutaneous Candidiasis
- Hypoparathyroidism
Type 2 - also known as Schmidt’s Syndrome
- Addison’s Disease
- Type 1 Diabetes
- Hypothyroidism
- Hypogonadism