Adrenal Insufficiency

clinical & laboratory manifestation of cortisol

deficiency

Rare, but fatal ( if untreated)

1. Primary :
acute : Addison’s crisis
chronic : Addison’s disease

2. Secondary
Adrenal Insufficiency
Etiology :
- Withdrawl from chronic GCC therapy

acute - Adrenal hemorrhage from anticoagulant

- Adrenal infarction secondary to septicemia

Primary
- Autoimmune adrenal atrophy
- Tuberculosis
chronic
- histoplasmosis

- sarcoidosis, hemochromatosis, etc

 Etiology :

- Post partum necrosis (Seehan’s syndr)

- Pituitary tumors
- Idopathic
Secondary - Granulomas (TBC, Sarcoidosis)
(pituitary)
- Infiltrative (leukemia, hemochromatosis)
- Destructive (trauma, surgery, metastases)
- post irradiation
Clinical manifestation

• weight loss, generalized weakness

• anorexia, vomitus

• postural hypotension

• hyperpigmentation of skin & mucosal

• hypoglycemia
Acute adrenal crisis :

• hypotension, shock

• febris (e.c. infection, hypoadrenalism)

• dehidration, anorexia, nausea, vomitus

• generalized weakness, apathy, confusion, coma

• Hypoglycemia, hyponatremia, hyperkalemia

Acute adrenal crisis :

Diagnosis : based on strongly suspicious

withdrawl of GCC
sepsis
bleeding

Diagnostic : glucose , Na+ , K+

Therapy
Acute :

- Hydrocortison 100 mg iv  100 mg infusion/8-h

- Dextrose 5% or NaCl 0.9%

Chronic :
- GCC & mineralocorticoid substitution
- Hydrocortison 20-25 mg/day or
Prednison/prednisolon in equivalent dose

2/3 – 3/4 dose : morning

1/3 – 1/4 dose : evening
Substitutional therapy :

Acute Adrenal Insufficiency Life threatening !!

• HC 100 mg-iv
• (followed by) HC 100 mg/8-h – iv
• (followed by) Cortisol Na-succinate/phospate 25 mg/6-h, im
• Infusion : NaCl 0.9% and glucose

Chronic Adrenal Insufficiency

• Cortisol 20-30 mg/day in divided dose
• Mineralocorticoid
Laboratory :
 Hypoglycemia
 Hyponatremia
 Hyperkalemia
 Cortisol or (-)
 ACTH : (primary) / (secondary)
 17-OCHS & 17-KS

Diagnosis :
 general weakness, body weight
 postural hypotension
 hyperpigmentation
 definitive : blood cortisol & ACTH
 Method:

-1-24 ACTH 25 U - im

Cortisol level 1-h pre & post injection of ACTH

1-h post injection :

N : cortisol level 3x
Addison’s disease :
no increase of cortisol
The Usage of CS in theraphy
 empiric

 principal thing : adjusted dose !,

 reevaluate ~ severity of disease

 single dose

 save but not in extreem dose

 long-term use : side effect

 withdrawll : acute adrenal insufficiency

Toxicity of Adrenocortical Steroid

1. Withdrawl Acute adrenal insuff !!

• fever, myalgia, arthralgia, malaise

2. long-term high-dose

• suppress the pituitary-adrenal function

• electrolyte imbalance
• hypertension
• hyperglycemia & glycosuria
• immunosuppression
• osteoporosis
• myopathy
• behaviour disturbance
• Cushing’s habitus
The Usage of CS in
Non-endocrinologic disease

1. Arthritis

2. Rheumatic carditis

3. Renal disease

4. Allergy

5. Asthma bronchiale