S17C225 - Adrenal Insufficiency and Adrenal Crisis

Question 1

Adrenal gland anatomy

Answer 1

• cortex : steroid hormones (cortisol, aldosterone, sex hormones) (glucocorticoids, mineralcorticoids, gonadocorticoids)(GFR)
• catecholamines: medulla

Question 2

Adrenal insufficiency

Answer 2

means not enough steroid hormones

Question 3

Adrenal crisis

Answer 3

-life-threatening exacerbation of adrenal insufficiency b/c of increased physiologic demand (infxn, MI, surgery, trauma, or pt stops their steroid tx)
(head trauma affects ACTH production)

Question 4

Adrenal insufficiency: pathophys

Answer 4

Primary adrenal ins: Addison Dz

• intrinsic adrenal gland dysfxn, decr cortisol and aldosterone
• occurs once 90% of gland is lost
• cause: Infxn, HIV, drugs, hemorrhage, sarvoid, mets, CAH

Secondary Adrenal insufficiency

• d/t HPA dysfunction resulting in decr ACTH
• only causes cortisol deficiency, aldosterone is ok
• cause: w/d from steroid therapy, pituitary dz, head trauma, sheehan syndrome

Question 5

Cortisol

Answer 5

• released from zona glomerulosa in cortex

- affects heart, vasculature, water excretion, lytes, metabolism

Question 6

Aldosterone

Answer 6

• secretion controlled by RAAS and serum K concn
• RAAS responds to volume, salt and posture
• potassiu, (hyperk) affects the adrenal cortex directly to increase secretion of aldosterone
• maintains Na and K concn and controls Na and volume balance

Question 7

Primary Adrenal Insufficiency

Answer 7

• Addison Dz
• 70% caused by autoimmune
• PGA
• TB is most common infx cause
• other infx cause: HIV
• infiltrative dz: amyloid, sarcoid ,adrenoleukodystrophy
• thrombosis/hemorrhage
• meds: ketoconazole

Question 8

PGA

Answer 8

• polyglandular autoimmune syndrome type I and II
• type I: candidiasis, hypoparathyroidism, adrenal failure
• type II: addison dz plus either hypothyroid or T1DM assoc with hypogonadism, pernicious anemia, primary biliary cirrhosis

Question 9

Secondary adrenal insufficiency

Answer 9

• d/o of HPA failure to secrete corticotropin or ACTH
• decreased cortisol but aldosterone is normal
• common cause: disruption of long-term corticosteroid tx
• other ause: pituitary necrosis/bleeding (sheehan), brain tumor, irradiation, surgery, trauma, infiltrative d/o of pituitary, infxs dz (TB, meningitis, HIV)

Question 10

Adrenal insufficiency: clinical presentation (primary)

Answer 10

• may have hx of HIV or were on glucocorticoid tx
• volume depleted and hypotensive
• hyperkalemic
• hyponatremic (d/t salt wasting)
• NOT cushingoid
• no other symptoms of pituitary hormone insufficiency

Other: wt loss, lethargy, weakness, GI sx (n/v/d),hypoglycemic

Question 11

AI: presentation (secondary)

Answer 11

• not as hypotensive or volume depleted as in primary, unless crisis present
• hypokalemic
• hypernatremic (aldosterone still functioning) or hyponatremic (d/t water retention)
• may be cushingoid
• may have other HPA abnormalities (Thyroid…)

Question 12

Adrenal crisis: presentation

Answer 12

• severe hypotension (refractory to vasopressors)
• dehydration
• wakness
• circulatory collapse
• delirium
• severe abdo pain, n/v
• confused, disoriented, lethargy
• sepsis w/o fever

Question 13

Adrenal crisis: Tx

Answer 13

• IMMEDIATE tx required
• fluids (D5NS)
• steroids - HCT 100mg IV bolus or dex 4mg
• vasopressors - give after steroid thx if unresponsive to fluid resusc
• supplementation - life-long glucocorticoids +/- aldosterone
• stress dose steroids

Question 14

Stress-dose steroids

Answer 14

• double regulary daily dose for 24-48h until symptosm improve
• don’t need to increase the aldosterone dose

Question 15

Steroid Equivalencies

Answer 15

• HCT =1
• cortisone = 0.8
• prednisone (prednisolone) = 4
• methylprednisolone = 5
• dexamethasone - 30-40