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Adrenal Insufficiency

Autoimmune adrenalitis is the most common cause of primary adrenal insufficiency. Adrenalitis caused by tuberculosis was once the most common cause. Autoimmune adrenalitis is sometimes accompanied by other autoimmune endocrine deficiencies, such as thyroid disease, diabetes mellitus, pernicious anemia, hypoparathyroidism, or ovarian failure Addison's disease, adrenalitis, adrenal insufficiency. Recently, AIDS and antiphospholipid syndrome have been implicated.

Iatrogenic tertiary adrenal insufficiency, a common secondary cause of adrenal insufficiency, results from suppression of hypothalamic-pituitary-adrenal function secondary to glucocorticoid administration. Secondary adrenal insufficiency may also result from pituitary.

Addison's disease may present with a wide range of symptoms and signs, including weakness, malaise, anorexia, hyperpigmentation (especially of the gingival mucosa, scars, and skin creases), vitiligo, postural hypotension, abdominal pain, nausea and vomiting, diarrhea, constipation, myalgias, and arthralgias. The most specific sign of

Acute adrenal crisis is characterized by rapid onset of hypotension, bradycardia, fever, hypoglycemia, and a progressive deterioration in mental status. Abdominal pain and diarrhea may be present.

Causes of Adrenal Insufficiency

Primary

Autoimmune adrenalitis

Tuberculosis

Adrenomyeloneuropathy

Systemic fungal infections

AIDS

Metastatic carcinoma

Isolated glucocorticoid deficiency

Adrenal hemorrhage, necrosis, or thrombosis

Secondary

Pituitary or metastatic tumor

Craniopharyngioma

Pituitary surgery or radiation therapy

Lymphocytic hypophysitis

Sarcoidosis

Histiocytosis

Empty sella syndrome

Hypothalamic tumors

Long-term glucocorticoid therapy

Postpartum pituitary necrosis (Sheehan's syndrome)

Necrosis or bleeding into a pituitary macroadenoma

Head trauma, lesions of the pituitary stalk

Pituitary or adrenal surgery for Cushing's syndrome

cytic anemia, lymphocytosis, mild eosinophilia, and a slightly elevated plasma creatinine concentration.

Evaluation and Diagnosis. Diagnosis depends on demonstrating inadequate cortisol production. Normally, plasma cortisol levels are high in the early morning and increase during stress. Therefore, a low plasma cortisol level in these

Initial Doses of Medications Used in Treating Adrenal Insufficiency

Drug Dosage

Replacement therapy

Hydrocortisone Adults: 25 mg per day, divided into 10-

and 15-mg doses

Children: 25 mg per m² per day, divided

into three doses

Cortisone acetate Adults: 37.5 mg per day, divided into

12.5- and 25.0-mg doses

Children: 32 mg per m² per day, divided

into three doses

Fludrocortisone Adults: 50 to 200 mcg in a single daily

(substitute for dose

aldosterone Children: 50 to 150 mcg in a single

[Florinet~]) daily dose)

Emergency therapy

Hydrocortisone Adults: 100-mg bolus dose, followed by

infusion of 100 to 200 mg per 24 hours

Children: infusion of 25 to 50 mg per m^~

per 24 hours