CHRONIC ADRENAL INSUFFICIENCY

Question 1

Essentials of diagnosis of a patient with chronic adrenal insufficiency

Answer 1

(a) Weakness, fatigability, anorexia, weight loss; nausea/vomiting, diarrhea;
abdominal pain, muscle and joint pains; amenorrhea.
(b) Sparse axillary hair; increased skin pigmentation, especially of creases, pressure
areas, and nipples.
(c) Hypotension, small heart.
(d) Potassium high, sodium low, blood urea nitrogen high
(e) Plasma cortisol levels are low or fail to rise after administration of corticotropic.
Elevated ACTH level.

Question 2

General Considerations of a patient with chronic adrenal insufficiency

Answer 2

(a) Addison disease is an uncommon disorder caused by destruction or dysfunction
of the adrenal cortices.
(b) Characterized by chronic deficiency of cortisol, aldosterone, and adrenal
androgens and causes skin pigmentation that can be subtle or strikingly dark.
(c) Secondary to pituitary failure (atrophy, necrosis, tumor), mineralocorticoid
production persists and hyperkalemia is not present.
(d) If ACTH is not elevated, skin pigmentary changes are not encountered.
(e) Etiology:
1) Autoimmune destruction of the adrenals is the most common cause
of Addison disease in the US.
2) Tuberculosis is a leading cause of Addison disease (rare in US),
decreased since the 1960s

Question 3

Clinical Findings of a patient with chronic adrenal insufficiency
Symptoms:

Answer 3

1) Weakness and fatigability
2) Weight loss
3) Myalgias
4) Arthralgia’s
5) Anorexia
6) Nausea/Vomiting
7) Anxiety
8) Mental irritability

Question 4

Clinical Findings of a patient with chronic adrenal insufficiency
Signs:

Answer 4

1) Hyperpigmentation skin changes
2) Hypopigmented skin (Vitiligo 10%)
3) Hypoglycemia
4) Hypotensive blood pressure
5) Nail beds (longitudinal pigmented bands)
6) Small heart
7) Scant axillary and pubic hair

Question 5

Lab/imaging findings of a patient with chronic adrenal insufficiency

Answer 5

(a) CBC with differential:
1) Moderate neutropenia
2) Lymphocytosis
3) Eosinophilia (Eos > 300/mcL)
(b) Serum Electrolytes:
1) Low Na+
2) Elevated K+
(c) Serum Glucose:
1) Low
(d) Cortisol:
1) Low (< 3 mcg/dL) at 8 am is diagnostic
2) ACTH elevation (usually > 200 pg/mL)
(e) Chest Radiograph:
1) Look for:
a) Tuberculosis
b) Fungal infection
c) Cancer
d) Edema
(f) Abdominal CT Scan:
1) Look for:
a) Small noncalcified adrenal in autoimmune Addison disease
b) Adrenals are enlarged in about 85% of cases due to metastatic or
granulomatous disease
c) Calcification is noted in 50% of TB cases

Question 6

Treatment of a patient with chronic adrenal insufficiency

Answer 6

(a) Refer to Medical Officer
(b) MEDEVAC as soon as possible
(c) Medications
1) Hydrocortisone is the drug of choice. Most Addison patients are well
maintained on 15 – 30 mg of hydrocortisone orally daily in two divided
doses.
2) Patients treated for acute adrenal insufficiency and diagnosed with
Addison’s disease require lifelong replacement therapy with both
glucocorticoids and mineralocorticoids.

Question 7

Disposition of a patient with chronic adrenal insufficiency

Answer 7

MEDEVAC

Question 8

Complications of a patient with chronic adrenal insufficiency

Answer 8

(a) Episodes of acute adrenal insufficiency which can result in shock and death if
untreated.
(b) The life expectancy of patients with Addison disease has been considered
reasonably normal, as long as they are compliant with taking their medications.