Adrenal Insufficiency

adrenal cortex zonae fasciculata and reticularis (cortisol and adrenal androgens) zona glomerulosa (aldosterone) adrenal cortex fetal zone (dehydroepiandrosterone)  androgens and estrogens.

Adrenal Insufficiency Metabolism (carbohydrates proteins fats) anti-inflammation react to stress Cortisol (glucocorticoid hormone) Adrenal cortex Aldosterone (mineralocorticoid hormone) Balance of Na+ K+ Adrenal Insufficiency Primary Addison’s Disease Secondary

Primary Adrenal Insufficiency (Addison’s Disease) damaged CRH (hypothalamus) ACTH (Pituitary) Renin-angiotensin II (Kidneys) Adrenal cortex Cortisol (glucocorticoid hormone) Aldosterone (mineralocorticoid hormone)

Secondary Adrenal Insufficiency CRH (hypothalamus) ACTH (Pituitary) Adrenal cortex Cortisol (glucocorticoid hormone)

Prevalence: 1-4 people per 100,000 in the US in all ages affects both males and females equally

Etiology primary adrenal insufficiency adrenal damage 70% : autoimmune process. 30%: tuberculosis (a common cause where tuberculosis is more prevalent) other bacterial, viral and fungal infections adrenal hemorrhage the spread of cancer into the adrenal glands. genetic abnormality of the adrenal glands(rarely)

Etiology Secondary adrenal insufficiency hypothalamus diesease pituitary disease Lack of ACTH receptors on adrenal cortex

Signs and Symptoms: Abdominal pain Decreased body hair Dehydration (only in Addison’s disease) Diarrhea or Constipation Dizziness and Fainting Fatigue Hyperpigmentation (only in Addison’s disease - dark patches of skin, especially in the folds of the skin. Sometime black freckles on the forehead, and face and/or discoloration around areas such as the nipples, lips, and rectum) Joint and muscle aches Low blood pressure Low blood sugar (hypoglycemia) Muscle weakness Salt craving (only in Addison’s disease) Vomiting Weight loss

Tests Diagnosis Primary Secondary (Addison’s disease) (Hypopituitarism) Cortisol Low Low Cortisol Low High (ACTH stimulation test) Aldosterone Low Normal ACTH High Low Renin High Normal

Tests Determine Severity and monitor the treatment Electrolytes (Sodium, Potassium, Chloride and Carbon dioxide) With Addison’s disease the sodium, chloride, and carbon dioxide levels are often low, while the potassium level may be very high. BUN and Creatinine: to monitor kidney function. Glucose: may be very low during an addisonian crisis.

Tests Occasionally used tests Insulin-induced hypoglycemia test. Glucose and cortisol levels are measured at predetermined intervals after an injection of insulin is used to stress the pituitary glands. In healthy people, blood glucose levels fall and cortisol concentrations increase. In those with adrenal insufficiency cortisol levels will remain low and glucose levels will fall then recover slowly. 21-hydroxylase autoantibodies. ordered when autoimmune Addison’s disease is suspected. They are considered a good marker of autoimmune Addison's disease but are not widely used at this time.

Tests Non-laboratory X-rays: calcification on the adrenal cortex that may be due to a tuberculosis infection. CT or MRI: size and shape of the adrenal glands and the pituitary. (The adrenal glands can be enlarged with infections and cancers. With autoimmune diseases and secondary adrenal insufficiency the adrenal glands are often normal or small in size.)

Treatment There is usually no cure for primary adrenal insufficiency, unless the cause is an infection, in which case, patients may regain some adrenal function. However, even when damage to the adrenal cortex is extensive and permanent, persons with Addison’s disease should be able to live healthy, relatively normal lives by replacing the missing hormones and observing a few precautions. In the case of secondary adrenal insufficiency, it is very rare for a patient to respond to treatment if the cause is pituitary damage or disease. However, if the underlying condition can be resolved, such as if the insufficiency is due to corticosteroid therapy, cortisol production may eventually resume.