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Adrenal insufficiency
Classification and external resources

Adrenal gland
ICD-10 E27.1-E27.4
ICD-9 255.4
eMedicine emerg/16
MeSH D000309

Adrenal insufficiency is a condition in which the adrenal glands, located above the kidneys, do not produce adequate amounts of steroid hormones (chemicals produced by the body that regulate organ function), primarily cortisol, but may also include impaired aldosterone production (a mineralcorticoid) which regulates sodium, potassium and water retention.[1][2] Craving for salt or salty foods due to the urinary losses of sodium is common.[3]

Addison's disease is the worst degree of adrenal insufficiency, which if not treated, results in severe abdominal pains, diarrhea, vomiting, profound muscle weakness and fatigue, extremely low blood pressure, weight loss, kidney failure, changes in mood and personality and shock may occur (adrenal crisis).[4] An adrenal crisis often occurs if the body is subjected to stress, such as an accident, injury, surgery, or severe infection; death may quickly follow.[4]

Adrenal insufficiency can also occur when the hypothalamus or the pituitary gland, both located at the base of the skull, doesn't make adequate amounts of the hormones that assist in regulating adrenal function.[1] [5] [6] This is called secondary adrenal insufficiency and is caused by lack of production of ACTH in the pituitary or lack of CRH in the hypothalamus. [7]

Contents

Types

There are two major types of adrenal insufficiency.

  • Secondary adrenal insufficiency is caused by impairment of the pituitary gland or hypothalamus.[8] These can be due to a form of cancer: a pituitary microadenoma, or a hypothalamic tumor; Sheehan's syndrome, which is associated with impairment of only the pituitary gland; or a past head injury.

Causes

Symptoms

The person may show symptoms of hypoglycemia, dehydration, weight loss and disorientation. They may experience weakness, tiredness, dizziness, low blood pressure that falls further when standing (orthostatic hypotension), muscle aches, nausea, vomiting, and diarrhea. These problems may develop gradually and insidiously. Addison's can present with tanning of the skin which may be patchy or even all over the body. In some cases a person with normally light skin may be mistaken for another race with darker pigmentation. Characteristic sites of tanning are skin creases (e.g. of the hands) and the inside of the cheek (buccal mucosa). Goitre and vitiligo may also be present.[4]

Diagnosis

If the person is in adrenal crisis, the ACTH stimulation test may be given. If not in crisis, cortisol, ACTH, aldosterone, renin, potassium and sodium are tested from a blood sample before the decision is made if the ACTH stimulation test needs to be performed. X-rays or CT of the adrenals may also be done.[1] The best test for adrenal insufficiency of autoimmune origin, representing more than 90% of all cases in a Western population, is measurement of 21-hydroxylase autoantibodies.[13]

Treatment

  • Adrenal crisis
  • Intravenous fluids[4]
  • Intravenous steroid (Solu-Cortef or Solumedrol), later hydrocortisone, prednisone or methylpredisolone tablets[4]
  • Rest
  • Cortisol deficiency (primary and secondary)
  • Adrenal cortical extract (usually in the form of a supplement, non prescription in the United States)
  • Hydrocortisone (Cortef) (between 20 and 35 mg)[4]
  • Prednisone (Deltasone) (7 1/2 mg)
  • Prednisolone (Delta-Cortef) (7 1/2 mg)
  • Methylprednisolone (Medrol) (6 mg)
  • Dexamethasone (Decadron) (1/4 mg, some doctors prescribe 1/2 to 1 mg, but those doses tend to cause side effects resembling Cushing's disease)
  • Mineralcorticoid deficiency (low aldosterone)
  • Fludrocortisone (Florinef) (To balance sodium, potassium and increase water retention)[4]

Simple diagnostic chart

Source of pathology CRH ACTH DHEA DHEA-S cortisol aldosterone renin Na K Causes5
'hypothalamus
('
tertiary)1
low low low low low3 low low low low tumor of the hypothalamus (adenoma), antibodies, environment, head injury
pituitary
(secondary)
high2 low low low low3 low low low low tumor of the pituitary (adenoma), antibodies, environment, head injury,
'surgical removal6, Sheehan's syndrome
adrenal glands
(primary)7
high high high high low4 low high low high tumor of the adrenal (adenoma), stress, antibodies, environment, Addison's, injury, surgical removal, miliary tuberculosis of the adrenal
1 Automatically includes diagnosis of secondary (hypopituitarism)
2 Only if CRH production in the hypothalamus is intact
3 Value doubles or more in stimulation
4 Value less than doubles in stimulation
5 Most common, doesn't include all possible causes
6 Usually because of very large tumor (macroadenoma)
7 Includes Addison's disease

See also

External links

References

  1. ^ a b c Eileen K. Corrigan (2007). "Adrenal Insufficiency (Secondary Addison's or Addison's Disease)". NIH Publication No. 90-3054. http://www.pituitary.org/disorders/addisons_disease.aspx.  
  2. ^ MeSH Adrenal+Insufficiency
  3. ^ Ten S, New M, Maclaren N (2001). "Clinical review 130: Addison's disease 2001". J. Clin. Endocrinol. Metab. 86 (7): 2909–22. doi:10.1210/jc.86.7.2909. PMID 12899587. http://jcem.endojournals.org/cgi/content/full/86/7/2909.  
  4. ^ a b c d e f g Ashley B. Grossman, MD (2007). "Addison's Disease". Adrenal Gland Disorders. http://www.merck.com/mmhe/sec13/ch164/ch164b.html.  
  5. ^ Brender E, Lynm C, Glass RM (2005). "JAMA patient page. Adrenal insufficiency". JAMA 294 (19): 2528. doi:10.1001/jama.294.19.2528. PMID 16287965. http://jama.ama-assn.org/cgi/content/full/294/19/2528.  
  6. ^ "Dorlands Medical Dictionary:adrenal insufficiency". http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?pg=/ppdocs/us/common/dorlands/dorland/four/000053970.htm.  
  7. ^ "Secondary Adrenal Insufficiency: Adrenal Disorders: Merck Manual Professional". http://www.merck.com/mmpe/sec12/ch153/ch153c.html.  
  8. ^ "hypopituitary". 2006. http://www.webmd.com/a-to-z-guides/hypopituitary.  
  9. ^ Thomas A Wilson, MD (2007). "Adrenal Insufficiency". Adrenal Gland Disorders. http://www.emedicine.com/PED/topic47.htm.  
  10. ^ Thomas A Wilson, MD (1999). Adrenoleukodystrophy. http://healthlink.mcw.edu/article/921176192.html.  
  11. ^ "Depression, opioids and cortisol release: evidence for a reduced response in depression". Burnett FE, Scott LV, Weaver MG, Medbak SH, Dinan TG , Department of Psychological Medicine, The Medical Colleges of St. Bartholomew's and the Royal London Hospitals, West Smithfield, UK. J Affect Disord 1999 Jun; 53(3):263-8. http://www.opioids.com/naloxone/depcrf.html. Retrieved December 28, 2009.  
  12. ^ "Oxycodone Disease Interactions". Drugs.com. http://www.drugs.com/disease-interactions/oxycodone.html#Adrenal_Insufficiency. Retrieved December 28, 2009.  
  13. ^ Winqvist, O; Karlsson, Fa; Kämpe, O (Jun 1992). "21-Hydroxylase, a major autoantigen in idiopathic Addison's disease". Lancet 339 (8809): 1559–62. doi:10.1016/0140-6736(92)91829-W. ISSN 0140-6736. PMID 1351548.   edit







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