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Updated: Dec 10 2021

Primary Adrenal Insufficiency

  • Snapshot
    • A 15-year-old man is brought to his pediatrician by his father for complaints of fatigue, weight loss, and recurrent episodes of nausea and vomiting. His symptoms have been occurring for more than 2 weeks and he can’t recall any clear precipitating factors. He denies fever, symptoms of upper respiratory infection, chest pain, palpitations, abdominal pain, or urinary symptoms. A physical examination demonstrates hyperpigmentation of his oral mucosa. A basic metabolic panel reveals hyponatremia and hyperkalemia.
  • Introduction
    • Clinical definition
      • disorder characterized by the loss of adrenal gland function leading to the deficiency of aldosterone (mineralcorticoids) and cortisol
      • can be either acute or chronic depending of the etiology
    • Associated conditions
      • approximately ½ of patients with autoimmune adrenal insufficiency have other autoimmune endocrine disorders (e.g., hypothyroidism)
  • Epidemiology
    • Demographics
      • autoimmune causes (which accounts for 70-90% of cases in the U.S.) occur predominantly within the female population
    • Risk factors
      • other autoimmune endocrinopathies
    • Pathogenesis
      • any process that damages the adrenal cortices and leading to a deficiency of aldosterone and cortisol
      • autoimmune adrenalitis (Addison disease)
        • most common cause in the U.S.
        • both humoral and cell-mediated immune mechanisms targeting the adrenal cortex
        • a small percentage of patients may have polyglandular autoimmune syndrome
      • infectious adrenalitis
        • tuberculosis (most common cause in the developing world)
        • disseminated fungal infections (e.g., histoplasmosis)
        • HIV infection
      • hemorrhagic infarction
        • Waterhouse-Friderichsen syndrome associated with meningococcemia (Neisseria meningococcal)
        • anticoagulant drug or heparin therapy (e.g., heparin-induced thrombocytopenia)
      • metastatic disease
        • commonly associated with lung, breast, and melanoma cancers
  • Presentation
    • Symptoms
      • fatigue
      • weight loss
      • nausea/vomiting
      • abdominal pain
      • muscle/joint pain
      • salt craving
      • adrenal crisis
    • Physical exam
      • skin and mucosal hyperpigmentation (if longstanding)
        • due to increased production of proopiomelanocortin (POMC), a prohormone that is cleaved into ACTH and melanocyte-stimulating hormone (MSH)
      • hypotension
      • auricular-cartilage calcification
      • vitiligo
  • Studies
    • Diagnostic testing
      • diagnostic approach
        • chronic adrenal insufficiency is often more difficult to diagnose than acute adrenal insufficiency
        • diagnosis is based on clinical presentation and confirmed with an endocrine evaluation
      • imaging
        • computed tomography (CT)
          • may demonstrate bilateral adrenal injury, hemorrhage, or infarction
      • studies
        • serum cortisol concentration (e.g., morning serum cortisol)
          • best initial test
          • low serum cortisol (e.g., less than 5 ug/dL) strongly suggests adrenal insufficiency
        • plasma ACTH concentration
          • best initial test but often not quickly available
          • high plasma ACTH concentration with low serum cortisol suggests primary adrenal insufficiency
        • ACTH stimulation test
          • will have low response to ACTH stimulation
        • plasma aldosterone and renin levels
          • will have low aldosterone and high renin levels
        • laboratory abnormalities secondary to low aldosterone
          • hyperkalemia
          • hyponatremia
          • hypoglycemia
          • metabolic acidosis
  • Differential
    • Secondary adrenal insufficiency
      • distinguishing factors
        • will not have hyperpigmentation on physical examination
        • will have low levels of ACTH
  • Treatment
    • First-line
      • glucocorticoid replacement therapy
        • e.g., hydrocortisone or dexamethasone
        • stress doses indicated at times of stress (e.g., surgery)
        • significant adverse effects with chronic use (e.g., osteoporosis)
      • mineralcorticoid replacement therapy
        • e.g., fludrocortisone
        • prevents sodium loss, intravascular volume depletion, and hyperkalemia
      • androgen replacement therapy
        • e.g., dehydroepiandrosterone (DHEA)
        • appears to improve mood and psychological well-being
        • adverse effects include hirsutism, acne, and increased sweating/odor
  • Complications
    • Adrenal crisis
      • medical emergency managed with schedule IV glucocorticoid
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