Adrenal insufficiency

GENERAL FEATURES


• Acute adrenal insufficiency is an emergency condition caused by an insufficient amount of cortisol.


• This crisis may occur during ­treatment of chronic adrenal ­insufficiency or it may be the ­primary manifestation.


• Causes 


– The condition may be triggered by stressful situations, such as 
trauma, surgery, infection, de­hydration, hyperthyroidism, or prolonged fasting in a patient with undiagnosed or untreated adrenal insufficiency.


– Sudden withdrawal of adreno­cortical hormone in a patient with chronic insufficiency or temporary insufficiency from exogenous corticosteroids may be a trigger.


– Bilateral adrenalectomy or removal of a functioning adrenal tumor; sudden destruction of the pituitary gland; or administration of etomidate during intubation are all potential causes.


– Injury to both adrenals from hemorrhage, trauma, anticoagulation therapy, thrombosis, or infection may also result in acute adrenal insufficiency.


CLINICAL ASSESSMENT


• Symptoms may include


– Weakness and fatigability


– Abdominal pain with nausea, vomiting, and diarrhea


– Anorexia or unintentional 
weight loss


– Fever


– Confusion and headache


• Physical examination may ­demonstrate


– Hypotension, tachycardia, and tachypnea


– Skin hyperpigmentation


– Sparse axillary hair


•Laboratory abnormalities in adrenal insufficiency:

• Sodium - reduced
• Chloride - reduced
• Bicarbonate - reduced
• Potassium - increased
• Uraemia
• Hypoglycaemia
• Abnormal LFTs
• Calcium - increased in 5-10%
• Normocytic anaemia
• Lymphocytosis
• Moderate eosinophilia

DIAGNOSIS


• Diagnosis is made by simplified cosyntropin test, in which an IM injection of synthetic adrenocor­ticotropic hormone (ACTH) is 
given and serum cortisol levels 
are measured between 30 and 
60 minutes later.


• Low serum cortisol level and ­decreased serum cortisol response are diagnostic.


TREATMENT


• If acute adrenal insufficiency is ­suspected, a serum cortisol level should be obtained immediately followed by administration of 100 to 300 mg IV Hydrocortisone with aggressive normal saline resuscitation, without waiting for the results.


• After the initial dose, IV infusions of 50 to 100 mg should be administered every 6 hours for the first day. The same dose should be given the second day every 8 hours and then adjusted based on symptoms.


– Hypoglycemia and other ­electrolyte abnormalities should be corrected with special attention to correcting hyperkalemia.


– Rehydration with 5% Dextrose and normal saline must be given.


– The precipitating cause should be treated. Broad-spectrum antibiotics should be considered, as bacterial infection frequently precipitates the crisis.


Prognosis

The prognosis for any patient with adrenal insufficiency will depend on the underlying cause. In those patients in whom the prognosis is not affected by the underlying pathology, replacement therapy should result in a return to health with a normal life expectancy.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.