Adrenal

disorders
 Steroid actions
 Amino acid catabolism (muscle wasting)…
gluconeogenesis in the liver.. Hyperglycemia… increased
insulin output… eventual beta cell failure… fat
deposition… diabetes
 Ca resorption, impairment of Ca absorbtion, increased
renal Ca excretion…. osteoporosis
 Increased gastric acidity… ulcer formation or aggravation
 K loss and Na retention… edema and hypertension
 Initially increased antibody release.. Eventually decreased
antibody production, lymphocytopenia, eosinopenia,
neutrophelia, polycythemia… susceptibility to infections
 Maintenance of arteriolar tone and blood pressure
Adrenal Insufficiency
 Causes of Adrenal
Insufficiency
 Primary
 Idiopathic (Addison disease)

 Tuberculosis

 Fungal infections

 Adrenal hemorrhage

 Congenital adrenal hypoplasia

 Sarcoidosis

 Amyloidosis

 Metastatic neoplasia

 Others
 Causes of Adrenal
Insufficiency
 Secondary
 After exogenous glucocorticoids

 After the cure of Cushing syndrome

(removing endogenous
glucocorticoids)
 Hypothalamic and pituitary lesions
Major Clinical Features in Adrenal
Insufficiency
 Weakness
 Skin
 Mucous membrane and skin pigmentation,

darkening of hair freckling, vitiligo, pigment

accentuation at nipples, and friction areas,
pigment concentration in skin creases and in scars
 Loss of weight, emaciation, anorexia, vomiting,
diarrhea
 Hypotension
 Salt craving
 Hypoglycemic episodes
 Diagnosis of Adrenal Insufficiency

Screening for Adrenal Insufficiency (AI)



Primary versus Secondary



 Confirmation

 Establishing Etiology
 Morning cortisol levels are a good screening test to rule out adrenal
insufficiency and levels above 20 mcg/dL are considered normal. Lower values
are not diagnostic of disease, but require further evaluation.

 Random ACTH levels: useful in the evaluation of primary adrenal insufficiency

as they are frequently elevated above 50 pg/mL in the majority of cases.

 Cortisol levels following 1 microgram ACTH injection should exceed 20 mcg/dL

and lower levels strongly suggest adrenal disease.

 Steroid cell antibodies (Adrenal Total Abs) : 70% of patients with autoimmune
adrenalitis, are helpful in the differential diagnosis of tuberculous adrenalitis.

 Low plasma aldosterone (<100 pmol/L) : associated with primary and

secondary aldosterone deficiencies.
 Confirmation of Adrenal Insufficiency

Standard Plasma
Consyntropin ACTH
Stim Test Level

urinary free cortisol test or urinary 17-ketosteroids test

in which the urine is collected over a 24-hour period.
 Post Priming Consyntropin Test
 mcg

 50
-

 40
-

 20
-


5-  Primary Secondary
 Pre 60’ post Pre 60 ‘ post

3-
 >18 - 20 mcg/dL 60” post : +
 Etiology of Adrenal Insufficiency


Primary

 Secondary
Autoimmune
-Pituitary Tumor
Metastatic
-Vascular
TB

Fungal
MRI
AIDS
Sella
CT

Adrenals
 Etiology of Addison’s Disease


CT adrenals

Small
Unenlarged
Enlarged


 Autoimmune  Biopsy
 Acute Adrenal Crisis

 Adrenal Decompensation

 Triggered by infections, anesthesia, surgery etc

Fatal if untreated


Easy when the patient is known Addisonian

Difficult when crisis is the first manifestation of AI

When in doubt treat first- diagnosis can be confirmed



or excluded later
  Adrenal Crisis
Rapid evolution
Nausea Hyponatremia
Vomiting Hyperkalemia
Abdominal Pain Hypoglycemia
Dizziness

Hypotension Hyperuricemia
Dehydration pre renal azotemia
Lethargy Eosinophilia
Muscle stiffness Natriuresis
Cardiac arrythmia

Shock
 Adrenal Crisis
 Treat as emergency

 If 60 minutes time is available Cortrosyn stim test

 If patient is too sick Draw cortisol

Start treatment :

 IV NaCl 0,9 %

 IV hydrocortisone 100
mg tid
 Hydrocortisone 20 mg =Dexamethasone 0.75 mg = Prednisone 5 mg =Prednisolone 4 mg
A 62 year old man seen in the MICU
Admitted for pneumonia and hypoxia.

On a ventilator.

His BP level dropped to 90/60

and was unresponsive to fluids and pressors

A random cortisol level was drawn.

The cortrosyn tests was not performed.

Therapy was instituted with intravenous

hydrocortisone at stress doses(100 mg q 8 hourly)

 Take-home
messages

1. Maintain High Index of Suspicion

2. Don’t be misled by a cortisol level in the “normal” range
3. The consyntropin stim test is a simple, safe clinic procedure
4. When in doubt in the ill patient, treat first, diagnose later