|
|
| (71 intermediate revisions by 9 users not shown) |
| Line 4: |
Line 4: |
| | Image = Illu adrenal gland.jpg | | | Image = Illu adrenal gland.jpg |
| | Caption = Adrenal gland | | | Caption = Adrenal gland |
| | DiseasesDB =
| |
| | ICD10 = {{ICD10|E|27|1|e|20}}-{{ICD10|E|27|4|e|20}}
| |
| | ICD9 = {{ICD9|255.4}}
| |
| | ICDO =
| |
| | OMIM =
| |
| | MedlinePlus =
| |
| | MeshID = D000309
| |
| }} | | }} |
| {{SI}} | | {{Secondary adrenal insufficiency}} |
|
| |
|
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
|
| |
|
| {{CMG}} | | {{CMG}} {{AE}} {{ADS}} |
|
| |
|
| {{SK}} hypocortisolism; hypocorticism; adrenocortical hypofunction | | {{SK}} hypocortisolism; hypocorticism; adrenocortical hypofunction |
|
| |
|
| ==Overview== | | ==[[Secondary adrenal insufficiency overview|Overview]]== |
| Adrenal insufficiency is a condition in which the [[adrenal gland]]s, located above the [[kidney]]s, do not produce adequate amounts of [[steroid hormone]]s (chemicals produced by the body that regulate organ function), primarily [[cortisol]], but may also include impaired [[aldosterone]] production (a [[mineralocorticoid]]) which regulates [[sodium]], [[potassium]] and water retention.<ref name="addisons_disease.aspx">{{cite journal | author=Eileen K. Corrigan |title=Adrenal Insufficiency (Secondary Addison's or Addison's Disease)|journal=NIH Publication No. 90-3054 |year=2007 |url=http://www.pituitary.org/disorders/addisons_disease.aspx}}</ref><ref>{{MeshName|Adrenal+Insufficiency}}</ref> Craving for salt or salty foods due to the urinary losses of sodium is common.<ref name="PMID 11443143">{{cite journal |author=Ten S, New M, Maclaren N |title=Clinical review 130: Addison's disease 2001 |journal=J. Clin. Endocrinol. Metab. |volume=86 |issue=7 | pages=2909–22 |year=2001 |pmid=11443143 |url=http://jcem.endojournals.org/cgi/content/full/86/7/2909 |doi=10.1210/jc.86.7.2909}}</ref>
| |
|
| |
|
| Adrenal insufficiency can also occur when the [[hypothalamus]] or the [[pituitary gland]], both located at the base of the [[Human skull|skull]], does not make adequate amounts of the hormones that assist in regulating adrenal function.<ref name="addisons_disease.aspx"/><ref name="urlJAMA -- Adrenal Insufficiency, November 16, 2005, Brender et al. 294 (19): 2528">{{cite journal |author=Brender E, Lynm C, Glass RM |title=JAMA patient page. Adrenal insufficiency |journal=JAMA |volume=294 |issue=19 |page=2528 |year=2005 |pmid=16287965 |doi=10.1001/jama.294.19.2528 |url=http://jama.ama-assn.org/cgi/content/full/294/19/2528}}</ref><ref name="urlDorlands Medical Dictionary:adrenal insufficiency">{{cite web |url=http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?pg=/ppdocs/us/common/dorlands/dorland/four/000053970.htm |title=Dorlands Medical Dictionary:adrenal insufficiency |work= |accessdate=}}</ref> This is called secondary adrenal insufficiency and is caused by lack of production of [[ACTH]] in the pituitary or lack of [[Corticotropin-releasing hormone|CRH]] in the hypothalamus.<ref name="urlSecondary Adrenal Insufficiency: Adrenal Disorders: Merck Manual Professional">{{cite web |url=http://www.merck.com/mmpe/sec12/ch153/ch153c.html |title=Secondary Adrenal Insufficiency: Adrenal Disorders: Merck Manual Professional |work= |accessdate=}}</ref>
| | ==[[Secondary adrenal insufficiency historical perspective|Historical Perspective]]== |
|
| |
|
| ==Classification== | | ==[[Secondary adrenal insufficiency classification|Classification]]== |
| There are three major types of adrenal insufficiency.
| |
|
| |
|
| * '''Primary adrenal insufficiency''' is due to impairment of the adrenal glands.
| | ==[[Secondary adrenal insufficiency pathophysiology|Pathophysiology]]== |
| ** One subtype is called [[idiopathic]] or unknown cause of adrenal insufficiency.
| |
| ** 80% are due to an [[autoimmune disease]] called [[Addison's disease]] or [[autoimmune adrenalitis]].
| |
| ** Other cases are due to [[congenital adrenal hyperplasia]] or an [[adenoma]] (tumor) of the adrenal gland.
| |
| * '''Secondary adrenal insufficiency''' is caused by impairment of the [[pituitary gland]] or [[hypothalamus]].<ref name="Hypopituitary">{{cite web |url=http://www.webmd.com/a-to-z-guides/hypopituitary |title=hypopituitary |year=2006}}</ref> The most common cause in the United States is exogenous steroid use. Other causes are a pituitary adenoma or microadenoma, hypothalamic tumor (surgical removal of a pituitary tumor can also suppress production of ACTH and lead to adrenal deficiency); [[Sheehan's syndrome]], which is associated with impairment of only the pituitary gland.
| |
| * '''Tertiary adrenal insufficiency''' is due to hypothalamic disease and decrease in corticotropin releasing factor (CRF).<ref>http://www.endotext.org/adrenal/adrenal13/adrenal13.htm</ref>
| |
|
| |
|
| == Causes == | | ==[[Secondary adrenal insufficiency causes|Causes]]== |
| ===Common Causes===
| |
| * '''Acute adrenal insufficiency'''
| |
| ** [[Addison's disease]] ([[autoimmune adrenalitis]])
| |
| ** [[Septic shock]]
| |
| ** [[Waterhouse-Friderichsen syndrome]]
| |
| ** [[Addison's disease#Addisonian crisis|Addisonian crisis]] in case of:
| |
| *** Discontinuing [[corticosteroid]] therapy without tapering the dosage
| |
| *** Surgery, illness or any other form of stress in patients with long-term [[corticosteroid]] therapy
| |
| * '''Chronic adrenal insufficiency'''
| |
| ** [[Addison's disease]]
| |
| ** [[Congenital adrenal hyperplasia|Congenital Adrenal Hyperplasia]]
| |
| ** [[Antiphospholipid syndrome]]
| |
| ** [[Haemochromatosis]]
| |
|
| |
|
| ===Causes by Organ System=== | | ==[[Differentiating Secondary adrenal insufficiency from other diseases|Differentiating Adrenal Insufficiency from other Diseases]]== |
| {|style="width:80%; height:100px" border="1"
| |
| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
| |
| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Arteritis]], [[Hypotension]], [[Hemorrhage]], [[Infarction]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Chemical / poisoning'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Dermatologic'''
| |
| |bgcolor="Beige"| [[POEMS syndrome]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Drug Side Effect'''
| |
| |bgcolor="Beige"| [[Aminoglutethimide]], [[Corticosteroid withdrawal]], [[Trilostane]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Ear Nose Throat'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Endocrine'''
| |
| |bgcolor="Beige"| [[Allgrove syndrome]], [[Achalasia-addisonian syndrome]], [[Adrenal aplasia]] / hypoplasia, [[Adrenal metastases]], After surgery of [[cortisol-secreting tumor]], [[Autoimmune polyendocrine syndrome type 2]], [[Bilateral adrenalectomy ]], [[Congenital adrenal hyperplasia]], [[Glucocorticoid deficiency 1]], [[IMAGE syndrome]], [[POEMS syndrome]], [[X-linked adrenal hypoplasia congenita]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Environmental'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Gastroenterologic'''
| |
| |bgcolor="Beige"| [[Allgrove syndrome]], [[Achalasia-addisonian syndrome]], [[Hemochromatosis ]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Genetic'''
| |
| |bgcolor="Beige"| [[Congenital adrenal hyperplasia]], [[Cytochrome P450 oxidoreductase deficiency]], [[Glycerol kinase deficiency]], [[Hereditary ACTH resistance]], [[IMAGE syndrome]], [[X-linked adrenal hypoplasia congenita]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Hematologic'''
| |
| |bgcolor="Beige"| [[Anticoagulation]], [[Coagulopathy ]], [[Embolus]], [[Leukemia]], [[Lymphoma ]], [[Thrombosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Iatrogenic'''
| |
| |bgcolor="Beige"| [[Iatrogenic]], [[Radiation therapy]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Infectious Disease'''
| |
| |bgcolor="Beige"| [[AIDS]], [[Blastomycosis]], [[CMV]], [[Coccidiomycosis]], [[Cryptococcosis]], [[Histoplasmosis ]], [[Mycobacterium avium intracellulaire]] ([[MAI]]), [[Sepsis]], [[Syphilis]], [[Toxoplasmosis]], [[Tuberculosis]], [[Waterhouse-Friderichson syndrome ]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Musculoskeletal / Ortho'''
| |
| |bgcolor="Beige"| [[IMAGE syndrome]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Neurologic'''
| |
| |bgcolor="Beige"| [[Adrenoleukodystrophy]], [[Coma]], [[Craniopharyngioma]], [[Panhypopituitarism]], [[POEMS syndrome]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Nutritional / Metabolic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Obstetric/Gynecologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Oncologic'''
| |
| |bgcolor="Beige"| [[Craniopharyngioma]], [[Kaposi's sarcoma]], [[Leukemia]], [[Lymphoma ]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Opthalmologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Overdose / Toxicity'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Psychiatric'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Pulmonary'''
| |
| |bgcolor="Beige"| [[Sarcoidosis]],
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Renal / Electrolyte'''
| |
| |bgcolor="Beige"| [[Uremia]], [[Waterhouse-Friderichson syndrome ]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Rheum / Immune / Allergy'''
| |
| |bgcolor="Beige"| [[Autoimmune]], [[Autoimmune polyendocrine syndrome type 2]], [[Sarcoidosis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Sexual'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Trauma'''
| |
| |bgcolor="Beige"| [[Trauma]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Urologic'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Dental'''
| |
| |bgcolor="Beige"| No underlying causes
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Miscellaneous'''
| |
| |bgcolor="Beige"| [[Amyloidosis]], [[Idiopathic]], [[Iatrogenic]], [[Radiation therapy]], [[Surgery]], Surgical removal of [[pituitary]], Surgical removal of [[hypothalamus]]
| |
| |-
| |
| |}
| |
|
| |
|
| ===Causes in Alphabetical Order=== | | ==[[Secondary adrenal insufficiency epidemiology and demographics|Epidemiology and Demographics]]== |
|
| |
|
| {{MultiCol}}
| | ==[[Secondary adrenal insufficiency risk factors|Risk Factors]]== |
| *[[Achalasia-addisonian syndrome]]<ref name="pmid11196451">{{cite journal |author=Huebner A, Yoon SJ, Ozkinay F, ''et al.'' |title=Triple A syndrome--clinical aspects and molecular genetics |journal=Endocr. Res. |volume=26 |issue=4 |pages=751–9 |year=2000 |month=November |pmid=11196451 |doi= |url=}}</ref>
| | |
| *[[Adrenal aplasia]] / [[Adrenal hypoplasia]]
| | ==[[Secondary adrenal insufficiency natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| *[[Adrenal metastases]]
| |
| *[[Adrenoleukodystrophy]]<ref name="pmid8441467">{{cite journal |author=Mosser J, Douar AM, Sarde CO, ''et al.'' |title=Putative X-linked adrenoleukodystrophy gene shares unexpected homology with ABC transporters |journal=Nature |volume=361 |issue=6414 |pages=726–30 |year=1993 |month=February |pmid=8441467 |doi=10.1038/361726a0 |url=}}</ref>
| |
| *After surgery of [[cortisol-secreting tumor]]
| |
| *[[AIDS]]<ref name="pmid22629505">{{cite journal |author=Shashidhar PK, Shashikala GV |title=Low dose adrenocorticotropic hormone test and adrenal insufficiency in critically ill acquired immunodeficiency syndrome patients |journal=Indian J Endocrinol Metab |volume=16 |issue=3 |pages=389–94 |year=2012 |month=May |pmid=22629505 |pmc=3354846 |doi=10.4103/2230-8210.95680 |url=}}</ref><ref name="pmid11217816">{{cite journal |author=Eledrisi MS, Verghese AC |title=Adrenal insufficiency in HIV infection: a review and recommendations |journal=Am. J. Med. Sci. |volume=321 |issue=2 |pages=137–44 |year=2001 |month=February |pmid=11217816 |doi= |url=}}</ref>
| |
| *[[Allgrove syndrome]]<ref name="pmid11196451">{{cite journal |author=Huebner A, Yoon SJ, Ozkinay F, ''et al.'' |title=Triple A syndrome--clinical aspects and molecular genetics |journal=Endocr. Res. |volume=26 |issue=4 |pages=751–9 |year=2000 |month=November |pmid=11196451 |doi= |url=}}</ref>
| |
| *[[Aminoglutethimide]]
| |
| *[[Amyloidosis]]
| |
| *[[Anticoagulation]]
| |
| *[[Arteritis]]
| |
| *[[Autoimmune]]
| |
| *[[Autoimmune polyendocrine syndrome type 2]]<ref name="pmid22506635">{{cite journal |author=Cocco C, Meloni A, Mariotti S, ''et al.'' |title=Novel neuronal and endocrine autoantibody targets in autoimmune polyendocrine syndrome type 1 |journal=Autoimmunity |volume=45 |issue=6 |pages=485–94 |year=2012 |month=September |pmid=22506635 |doi=10.3109/08916934.2012.680632 |url=}}</ref>
| |
| *[[Bilateral adrenalectomy]]
| |
| *[[Blastomycosis]]<ref name="pmid6266250">{{cite journal |author=Osa SR, Peterson RE, Roberts RB |title=Recovery of adrenal reserve following treatment of disseminated South American blastomycosis |journal=Am. J. Med. |volume=71 |issue=2 |pages=298–301 |year=1981 |month=August |pmid=6266250 |doi= |url=}}</ref>
| |
| *[[CMV]]<ref name="pmid19765472">{{cite journal |author=Ardalan M, Shoja MM |title=Cytomegalovirus-induced adrenal insufficiency in a renal transplant recipient |journal=Transplant. Proc. |volume=41 |issue=7 |pages=2915–6 |year=2009 |month=September |pmid=19765472 |doi=10.1016/j.transproceed.2009.07.024 |url=}}</ref>
| |
| *[[Coagulopathy]]
| |
| *[[Coccidiomycosis]]
| |
| *[[Coma]]
| |
| *[[Congenital adrenal hyperplasia]]
| |
| *[[Corticosteroid]] withdrawal
| |
| *[[Craniopharyngioma]]<ref name="pmid18050601">{{cite journal |author=Mihalache A, Lamy O, Waeber G, Schneider A |title=[Adrenal insufficiency and hypercalcemia--an unusual presentation] |language=German |journal=Praxis (Bern 1994) |volume=96 |issue=45 |pages=1761–5 |year=2007 |month=November |pmid=18050601 |doi= |url=}}</ref>
| |
| *[[Cryptococcosis]]<ref name="pmid9671046">{{cite journal |author=Kawamura M, Miyazaki S, Mashiko S, ''et al.'' |title=Disseminated cryptococcosis associated with adrenal masses and insufficiency |journal=Am. J. Med. Sci. |volume=316 |issue=1 |pages=60–4 |year=1998 |month=July |pmid=9671046 |doi= |url=}}</ref>
| |
| *[[Cytochrome P450 oxidoreductase deficiency]]
| |
| *[[Embolus]]
| |
| *[[Glucocorticoid deficiency 1]]<ref name="pmid22337906">{{cite journal |author=Turan S, Hughes C, Atay Z, ''et al.'' |title=An atypical case of familial glucocorticoid deficiency without pigmentation caused by coexistent homozygous mutations in MC2R (T152K) and MC1R (R160W) |journal=J. Clin. Endocrinol. Metab. |volume=97 |issue=5 |pages=E771–4 |year=2012 |month=May |pmid=22337906 |pmc=3396854 |doi=10.1210/jc.2011-2414 |url=}}</ref>
| |
| *[[Glycerol kinase deficiency]]<ref name="pmid2883886">{{cite journal |author=Francke U, Harper JF, Darras BT, ''et al.'' |title=Congenital adrenal hypoplasia, myopathy, and glycerol kinase deficiency: molecular genetic evidence for deletions |journal=Am. J. Hum. Genet. |volume=40 |issue=3 |pages=212–27 |year=1987 |month=March |pmid=2883886 |pmc=1684111 |doi= |url=}}</ref>
| |
| *[[Hemochromatosis]]<ref name="pmid8650756">{{cite journal |author=Pedersen-Bjergaard U, Thorsteinsson B, Kirkegaard BC |title=[Pituitary function in hemochromatosis] |language=Danish |journal=Ugeskr. Laeg. |volume=158 |issue=13 |pages=1818–22 |year=1996 |month=March |pmid=8650756 |doi= |url=}}</ref>
| |
| {{ColBreak}}
| |
| *[[Hemorrhage]]
| |
| *[[Hereditary ACTH resistance]]
| |
| *[[Histoplasmosis]]
| |
| *[[Hypotension]]
| |
| *[[Iatrogenic]]
| |
| *[[Idiopathic]]
| |
| *[[IMAGE syndrome]]<ref name="pmid14760276">{{cite journal |author=Pedreira CC, Savarirayan R, Zacharin MR |title=IMAGe syndrome: a complex disorder affecting growth, adrenal and gonadal function, and skeletal development |journal=J. Pediatr. |volume=144 |issue=2 |pages=274–7 |year=2004 |month=February |pmid=14760276 |doi=10.1016/j.jpeds.2003.09.052 |url=}}</ref>
| |
| *[[Infarction]]
| |
| *[[Kaposi's sarcoma]]
| |
| *[[Leukemia]]
| |
| *[[Lymphoma]]
| |
| *[[Mycobacterium avium intracellulaire]] ([[MAI]])<ref name="pmid1758516">{{cite journal |author=Weits J, Sprenger HG, Ilic P, van Klingeren B, Elema JD, Steensma JT |title=[Mycobacterium avium disease in AIDS patients; diagnosis and therapy] |language=Dutch; Flemish |journal=Ned Tijdschr Geneeskd |volume=135 |issue=52 |pages=2485–9 |year=1991 |month=December |pmid=1758516 |doi= |url=}}</ref>
| |
| *[[Panhypopituitarism]]
| |
| *[[POEMS syndrome]]<ref name="pmid12456500">{{cite journal |author=Dispenzieri A, Kyle RA, Lacy MQ, ''et al.'' |title=POEMS syndrome: definitions and long-term outcome |journal=Blood |volume=101 |issue=7 |pages=2496–506 |year=2003 |month=April |pmid=12456500 |doi=10.1182/blood-2002-07-2299 |url=}}</ref>
| |
| *[[Radiation therapy]]
| |
| *[[Sarcoidosis]]<ref name="pmid16526262">{{cite journal |author=Gostiljac DM, Dordević PB, Maric-zivković J, Canović F |title=[Sarcoidosis localized in endocrine glands] |journal=Med. Pregl. |volume=58 Suppl 1 |issue= |pages=25–9 |year=2005 |pmid=16526262 |doi= |url=}}</ref>
| |
| *[[Sepsis]]
| |
| *[[Surgery]]
| |
| *Surgical removal of [[hypothalamus]]
| |
| *Surgical removal of [[pituitary]]
| |
| *[[Syphilis]]
| |
| *[[Thrombosis]]
| |
| *[[Toxoplasmosis]]
| |
| *[[Trauma]]
| |
| *[[Trilostane]]
| |
| *[[Tuberculosis]]
| |
| *[[Uremia]]
| |
| *[[Waterhouse-Friderichson syndrome ]]
| |
| *[[X-linked adrenal hypoplasia congenita]]
| |
| {{EndMultiCol}}
| |
|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
| ===Symptoms===
| | [[Secondary adrenal insufficiency history and symptoms| History and Symptoms]] | [[Secondary adrenal insufficiency physical examination | Physical Examination]] | [[Secondary adrenal insufficiency laboratory findings|Laboratory Findings]] | [[Secondary adrenal insufficiency electrocardiogram|Electrocardiogram]] | [[Secondary adrenal insufficiency chest x ray|Chest X Ray]] | [[Secondary adrenal insufficiency CT|CT]] | [[Secondary adrenal insufficiency MRI|MRI]] | [[Secondary adrenal insufficiency ultrasound|Ultrasound]] | [[Secondary adrenal insufficiency other imaging findings|Other Imaging Findings]] | [[Secondary adrenal insufficiency other diagnostic studies|Other Diagnostic Studies]] |
| There is often the slow insidious onset of the following symptoms (in alphabetical order):
| |
| *[[Dehydration]]
| |
| *[[Diarrhea]]
| |
| *[[Abdominal pain]]
| |
| *[[Disorientation]]
| |
| *[[Dizziness]]
| |
| *[[Muscle aches]]
| |
| *[[Nausea]]
| |
| *[[Tanning]] of the skin that may be patchy or even all over the body. Characteristic sites of tanning are skin creases (e.g. of the hands) and the inside of the cheek ([[buccal mucosa]]).
| |
| *[[Tiredness]] - [[fatigue]]
| |
| *[[Vomiting]]
| |
| *[[Weakness]]
| |
| *[[Weight loss]]
| |
| | |
| ===Physical Examination===
| |
| ====Appearance====
| |
| * The patient may be [[dehydrated]] and [[lethargic]].
| |
| | |
| ====Vital Signs====
| |
| * [[Hypotension|Low blood pressure]] that falls further when standing ([[orthostatic hypotension]])
| |
| * [[Cardiovascular collapse]] may be present
| |
| | |
| ====Skin====
| |
| * There can be tanning of the skin. [[Tanning]] of the skin that may be patchy or even all over the body. Characteristic sites of tanning are skin creases (e.g. of the hands) and the inside of the cheek ([[buccal mucosa]]).
| |
| * [[Vitiligo]] may also be present.<ref name="ch164b.html"/>
| |
| * Absence of axillary and pubic hair in females as a result of loss of adrenal [[androgens]].
| |
| * [[Pallor]] may be present.
| |
| | |
| ====Neck====
| |
| * [[Goitre]] may be present
| |
| | |
| ===Extremities===
| |
| * [[Weakness]]
| |
| | |
| ===Neurologic===
| |
| * [[Confusion]] may be present
| |
| * [[Seizures]] may be present.
| |
| | |
| ===Laboratory Findings===
| |
| ====ACTH Stimulation Test====
| |
| If the person is in [[adrenal crisis]], the [[ACTH stimulation test]]<ref>{{cite journal|pmid=21656493 | doi=10.1024/0040-5930/a000174 | volume=68 | issue=6 | title=[Adrenal insufficiency--diagnosis and treatment in clinical practice] | year=2011 | month=June | author=Henzen C | journal=Ther Umsch | pages=337–43}}</ref> 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.<ref name="addisons_disease.aspx"/> The best test for adrenal insufficiency of autoimmune origin, representing more than ninety percent of all cases in a Western population, is measurement of 21-hydroxylase autoantibodies.
| |
| {| border="4" cellspacing="1" cellpadding="4" style="text-align:center; margin:10px;"
| |
| |-
| |
| | style="background:#ddcef2" | '''Source of pathology|| style="background:#cef2e0" |'''CRH|| style="background:#cef2e0" |'''ACTH|| style="background:#cef2e0" |'''DHEA|| style="background:#cef2e0" |'''DHEA-S|| style="background:#cef2e0" |'''cortisol||style="background:#cef2e0;" |'''aldosterone|| style="background:#cef2e0" |'''renin|| style="background:#cef2e0" |'''Na|| style="background:#cef2e0" |'''K|| style="background:#f2e0ce" |'''Causes'''<sup>5</sup>
| |
| |-
| |
| | style="background:#cedff2" | '''hypothalamus'''<br>(tertiary)<sup>1</sup>|| style="background:#F8F8F8" |low|| style="background:#F8F8F8"|low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low<sup>3</sup>||style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low||style="background:#F8F8F8" |tumor of the hypothalamus (adenoma), [[antibodies]], [[environment (biophysical)|environment]] (i.e. toxins), [[head injury]]
| |
| |-
| |
| | style="background:#cedff2" | '''pituitary'''<br>(secondary)|| style="background:#F8F8F8" |high<sup>2</sup>|| style="background:#F8F8F8"|low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low<sup>3</sup>||style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low||style="background:#F8F8F8" |tumor of the pituitary ([[adenoma]]), antibodies, environment, head injury,<br>'''surgical removal'''<sup>6</sup>, Sheehan's syndrome
| |
| |-
| |
| | style="background:#cedff2" | '''adrenal glands'''<br>(primary)<sup>7</sup>|| style="background:#F8F8F8" |high|| style="background:#F8F8F8"|high|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |low<sup>4</sup>||style="background:#F8F8F8" |low|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |high||style="background:#F8F8F8" |tumor of the adrenal (adenoma), [[Stress (biology)|stress]], antibodies, environment, [[Addison's Disease]], [[Physical trauma|trauma]], surgical removal ([[Segmental resection|resection]]), [[wikt:miliary|miliary]] [[tuberculosis]] of the adrenal
| |
| |}
| |
| | |
| {| border="2" cellspacing="1" cellpadding="2" style="margin:10px;"
| |
| |-
| |
| | '''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, does not include all possible causes
| |
| |-
| |
| | '''6'''|| Usually because of very large tumor (macroadenoma)
| |
| |-
| |
| | '''7'''|| Includes Addison's disease
| |
| |}
| |
| | |
| ====Routine Investigations====
| |
| * [[Complete blood count]] and differential count - [[Eosinophilia]] and [[lymphocytosis]] (increased number of [[eosinophil]]s or [[lymphocyte]]s, two types of [[white blood cell]]s). [[Normocytic anemia]] may be present.
| |
| * [[Hypoglycemia]], low blood sugar (worse in children)
| |
| * [[Serum electrolytes]]:
| |
| ** [[Hyponatraemia]] (low blood sodium levels)
| |
| ** [[Hyperkalemia]] (raised blood [[potassium]] levels), due to loss of production of the hormone [[aldosterone]]
| |
| ** Mild [[hypercalcemia]] - in 20% patients
| |
| ** Mild non–anion-gap [[metabolic acidosis]]
| |
| * Serum [[cortisol]] - decreased (<25mcg/dL)
| |
| * Urine and sweat [[sodium]] - elevated
| |
| * Elevated [[BUN]] and [[creatinine]] - when [[hypovolemia]] is the cause.
| |
| * [[Prolactin]] - mild elevation may be present.
| |
|
| |
|
| ==Treatment== | | ==Treatment== |
| *;Adrenal crisis
| | [[Secondary adrenal insufficiency medical therapy|Medical Therapy]] | [[Secondary adrenal insufficiency surgery|Surgery]] | [[Secondary adrenal insufficiency primary prevention|Primary Prevention]] | [[Secondary adrenal insufficiency secondary prevention|Secondary Prevention]] | [[Secondary adrenal insufficiency cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Secondary adrenal insufficiency future or investigational therapies|Future or Investigational Therapies]] |
| **Intravenous fluids<ref name="ch164b.html"/>
| |
| **Intravenous steroid ([[Solu-Cortef]]/injectable hydrocortisone) later hydrocortisone, prednisone or methylpredisolone tablets<ref name="ch164b.html"/>
| |
| **Rest
| |
| | |
| *;Cortisol deficiency (primary and secondary)
| |
| **[[Hydrocortisone]] (Cortef)
| |
| **[[Prednisone]] (Deltasone)
| |
| **[[Prednisolone]] (Delta-Cortef)
| |
| **[[Methylprednisolone]] (Medrol)
| |
| **[[Dexamethasone]] (Decadron)
| |
|
| |
|
| *;Mineralocorticoid deficiency (low aldosterone)
| | ==Case Studies== |
| **Fludrocortisone Acetate
| | [[Secondary adrenal insufficiency case study one|Case#1]] |
| (To balance sodium, potassium and increase water retention)
| |
|
| |
|
| ==See also== | | ==Related Chapters== |
| * [[Addison disease]], primary adrenocortical insufficiency | | * [[Addison disease]], primary adrenocortical insufficiency |
| * [[ACTH stimulation test]] | | * [[ACTH stimulation test]] |
| * [[Cushing's syndrome]], overproduction of cortisol | | * [[Cushing's syndrome]], overproduction of [[cortisol]] |
| * [[Insulin tolerance test]], another test used to identify sub-types of adrenal insufficiency | | * [[Insulin tolerance test]], another test used to identify sub-types of [[adrenal insufficiency]]. |
| * [[Adrenal fatigue]] (hypoadrenia), a term used in [[alternative medicine]] to describe a believed exhaustion of the adrenal glands | | * [[Adrenal fatigue]] (hypoadrenia), a term used in [[alternative medicine]] to describe a believed exhaustion of the [[adrenal glands]]. |
| | |
| ==References==
| |
| {{reflist|2}}
| |
|
| |
|
| {{Endocrine pathology}} | | {{Endocrine pathology}} |
| Line 343: |
Line 51: |
| [[Category:Endocrinology]] | | [[Category:Endocrinology]] |
| [[Category:Disease]] | | [[Category:Disease]] |
|
| |
| [[ca:Insuficiència suprarenal]]
| |
| [[de:Nebennierenrindeninsuffizienz]]
| |
| [[es:Insuficiencia adrenal]]
| |
| [[fr:Insuffisance surrénalienne]]
| |
| [[he:תת פעילות בלוטת יותרת הכליה]]
| |
| [[ja:急性副腎不全]]
| |
| [[ru:Гипокортицизм]]
| |
|
| |
|
| {{WikiDoc Help Menu}} | | {{WikiDoc Help Menu}} |
| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |
