Adrenal Insufficiency

Question 1

Define Adrenal Insufficiency

Answer 1

Deficiency of adrenal cortical hormones i.e. mineralocorticoids, glucocorticoids and androgens

Question 2

Aetiology of Adrenal Insufficiency

Answer 2

Primary: Addison’s (auto-immune) - 70%, most common in the UK)
Infections: TB (most common worlwide), meningococcal septicaemia, CMV
Infiltration: metastasis
Infarction: thrombophilia
Inherited: adrenoleukodystrophy, ACTH receptor mutation, congenital adrenal hyperplasia
Surgica: bilateral adrenalectomy
Secondary to pituitary or hypothalamic disease
Iatrogenic: sudden cessation of long-term steroid therapy (most common)

Question 3

Symptoms of Adrenal Insufficiency

Answer 3

Dizziness
Anorexia
Weight loss
Diarrhoea
Vomiting
Abdominal pain
Lethargy 
Weakness
Depression

Question 4

Symptoms and signs of an acute Addisonian Crisis

Answer 4

Acute adrenal insufficiency with major haemodynamic collapse, often precipitate by stress

Syncope 
Dehydration (from vomiting and diarrhoea)
Hypoglycaemia
Confusion
Seizures (electrolyte imbalanced)

Hypotensive shock
Tachycardia
Pale, cold, clammy
Oliguria

Question 5

Signs of Adrenal Insufficiency on examination

Answer 5

Postural hypotension
Skin hyperpigmentation (buccal mucosa, scars, skin creases, bails, pressure points)
Loss of body hair (women)
Autoimmune conditions e.g. vitiligo

Question 6

Investigations for Adrenal Insufficiency

Answer 6

U+Es: hyperkalaemia + hyponatraemia
Cortisol: 9am cortisol low
Autoantibodies: Present in Addison’s
Tuberculin skin testing: TB

Short synacthen test: Cortisol <550 after tetracosactrin given
Long synacthen test: No increase in cortisol

Question 7

Investigations in Addisonian crisis

Answer 7

FBC: neutrophilia
U+Es: Raised urea, hyponatraemia + hyperkalaemia
Calcium: may be raised
Glucose: may be reduced

Question 8

Management for Adrenal Insufficiency

Answer 8

Glucocorticoid and mineralocorticoid replacement - hydrocortisone + fludrocortisone

Must increase hydrocortisone dose during acute illness or stress
With hypothyroidism - give hydrocortisone before thyroxine
+ steroid warnign card, medi-alert bracelet

Question 9

Prognosis for Adrenal Insufficiency

Answer 9

Adrenal function will rarely recover

Normal life expectancy can be expected with treatment