Day 4 - Adrenal Insufficiency

Adrenal insufficiency can present with an insidious development of symptoms or in acute adrenal crisis. Patients often report non-specific symptoms of anorexia, nausea, vomiting, fatigue and weight loss.

• Lack of cortisol can lead to hypoglycemia or unexplained reduction in insulin requirements in diabetic patients

• Mineralocorticoid insufficiency can lead to orthostatic hypotension

  • Ask about muscle cramps, abdominal pain and salt craving that come along with dysregulated sodium and potassium levels

• Lack of androgens is often inconsequential, but may lead to loss of axillary or pubic hair in women (not seen in men due to testicular production of androgens compensating for lack of adrenal DHEA)

• Primary AI leads to skin pigmentation changes due to the elevation of ACTH which stimulates melanocytes and results in darkening of the skin, not seen in secondary

Primary adrenal insufficiency

• Most commonly secondary to autoimmune process

  • Ask about other autoimmune conditions such as thyroid disease and diabetes suggestive of autoimmune polyendocrine syndromes.

• Exogenous steroid use generating adrenal suppression

  • Any more than 7.5 mg per day of Prednisone equivalent for more than 3 weeks can cause adrenal insufficiency

  • High doses of opiates can also induce adrenal suppression

• Consider previous infections such as TB, HIV and fungal infections and inquire about risk factors

• Consider adrenal hemorrhage or infarction in cases of trauma, sepsis or any thrombotic states such as antiphospholipid syndrome

Secondary adrenal insufficiency - problem lies at the level of the pituitary

• Pituitary tumours

  • Physical compression can create visual changes (bitemporal hemianopsia) & other pituitary hormone dysfunction (hypothyroidism, hypogonadism, hyperprolactinemia, diabetes insipidus)

• Infiltrative diseases such as hemochromatosis, sarcoidosis or amyloidosis

• In the post-partum period, pituitary ischemic necrosis in cases of Sheehan’s syndrome or lymphocytic hypophysitis

• Mineralocorticoids remain intact = no hyperkalemia or skin hyperpigmentation

Adrenal Crisis

Characterized by shock with persistent hypotension, altered LOC, hypoglycemia, fever or abdominal pain.

Treatment:

• Hydrocortisone 100mg IV q6h or Dexamethasone 4mg IV q6h

Corticosteroid equivalency - McMaster Internal Medicine Red Book 8th edition