Metabolic acidosis and lactic acidosis differential diagnosis: Difference between revisions

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==Metabolic Acidosis and Lactic Acidosis Differential Diagnosis==
==Metabolic Acidosis and Lactic Acidosis Differential Diagnosis==
'''Differential diagnosis of metabolic acidosis is as follow:'''<ref name="pmid17936961">{{cite journal |vauthors=Lim S |title=Metabolic acidosis |journal=Acta Med Indones |volume=39 |issue=3 |pages=145–50 |date=2007 |pmid=17936961 |doi= |url=}}</ref><ref name="MorrisLow2008">{{cite journal|last1=Morris|first1=C. G.|last2=Low|first2=J.|title=Metabolic acidosis in the critically ill: Part 1. Classification and pathophysiology|journal=Anaesthesia|volume=63|issue=3|year=2008|pages=294–301|issn=00032409|doi=10.1111/j.1365-2044.2007.05370.x}}</ref><ref name="pmid18336491">{{cite journal |vauthors=Morris CG, Low J |title=Metabolic acidosis in the critically ill: part 2. Causes and treatment |journal=Anaesthesia |volume=63 |issue=4 |pages=396–411 |date=April 2008 |pmid=18336491 |doi=10.1111/j.1365-2044.2007.05371.x |url=}}</ref><ref name="Casaletto2005">{{cite journal|last1=Casaletto|first1=Jennifer J.|title=Differential Diagnosis of Metabolic Acidosis|journal=Emergency Medicine Clinics of North America|volume=23|issue=3|year=2005|pages=771–787|issn=07338627|doi=10.1016/j.emc.2005.03.007}}</ref>
'''Differential diagnosis of metabolic acidosis and lactic acidosis is as follow:'''<ref name="pmid179369612">{{cite journal |vauthors=Lim S |title=Metabolic acidosis |journal=Acta Med Indones |volume=39 |issue=3 |pages=145–50 |date=2007 |pmid=17936961 |doi= |url=}}</ref><ref name="MorrisLow20082">{{cite journal|last1=Morris|first1=C. G.|last2=Low|first2=J.|title=Metabolic acidosis in the critically ill: Part 1. Classification and pathophysiology|journal=Anaesthesia|volume=63|issue=3|year=2008|pages=294–301|issn=00032409|doi=10.1111/j.1365-2044.2007.05370.x}}</ref><ref name="pmid183364912">{{cite journal |vauthors=Morris CG, Low J |title=Metabolic acidosis in the critically ill: part 2. Causes and treatment |journal=Anaesthesia |volume=63 |issue=4 |pages=396–411 |date=April 2008 |pmid=18336491 |doi=10.1111/j.1365-2044.2007.05371.x |url=}}</ref><ref name="Casaletto20052">{{cite journal|last1=Casaletto|first1=Jennifer J.|title=Differential Diagnosis of Metabolic Acidosis|journal=Emergency Medicine Clinics of North America|volume=23|issue=3|year=2005|pages=771–787|issn=07338627|doi=10.1016/j.emc.2005.03.007}}</ref>


'''To review differential diagnosis of  high anion gap metabolic acidosis, click [[High anion gap metabolic acidosis differential diagnosis|here]].'''
'''To review differential diagnosis of  metabolic acidosis, click [[Metabolic acidosis differential diagnosis|here]].'''
 
'''To review differential diagnosis of  high osmolar gap metabolic acidosis, click here.'''
 
'''To review differential diagnosis of  metabolic acidosis and lactic acidosis, click here.'''


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Latest revision as of 16:40, 30 May 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Metabolic Acidosis and Lactic Acidosis Differential Diagnosis

Differential diagnosis of metabolic acidosis and lactic acidosis is as follow:[1][2][3][4]

To review differential diagnosis of metabolic acidosis, click here.

Category Disease Mechanism Clinical Paraclinical Gold standard diagnosis Other findings
Symptoms Signs Lab data
ABG CBC Chemistry Renal U/A
↑ acid
production 		Loss of
bicarbonate 		↓ renal acid
excretion 		Fever N/V Diarrhea Dyspnea Toxic/ill BP Dehydration Level of consciousness HCO3− paCO2 O2 WBC Hb BS Cl− K+ Na+ Ketones Lactic acid Serum AG[5] Osmolar gap[6] Bun Cr Urine pH Urine AG Urine ketone
Toxin/Medication[7] Alcohol poisoning[8][9] + − − − + − − + ↓ ↑ + ↓ ↓ ↓ ↓ Nl Nl ↑ ↑ ↑ Nl + ↑ ↑ ↑ Nl or ↑ Nl or ↑ ↓ + + Clinical manifestation
+ − − − + − − + ↓ + ↓ ↓ ↓ ↓ Nl Nl Nl ↑ ↑ Nl + ↑ Nl ↑ Nl Nl or ↑ ↓ + + Clinical manifestation
  • Not applicable
Toluene toxicity[11] + − + − + − − + ↓ − ↓ ↓↓ ↓ Nl Nl Nl Nl Nl ↓ Nl − ↑ Nl or ↑ Nl ↑ ↑ ↓ − + Clinical manifestation
  • Most widely abused inhaled drugs
Salicylates overdose[12] + − − − + − + + ↓ + ↓ ↓ ↓↓ ↓ Nl Nl Nl to ↓ Nl ↓ Nl − ↑ ↑ ↑ ↑ ↑ ↓ − − Clinical and elevated serum salicylate level
Metformin[13] + − − − + − − + ↓ ± Agitated ↓ ↓ Nl Nl to ↑ ↓ ↓ Nl Nl Nl Nl ↑ ↑ ↑ Nl or ↑ Nl ↓ − − Clinical manifestation
Isoniazid[14] + − − − + − − + ↑ + Agitated ↓ ↓ Nl Nl ↓ Nl Nl Nl Nl Nl ↑ ↑ Nl Nl or ↑ Nl ↓ − − Clinical manifestation
Acetazolamide[15] − + − − − − − − ↓ + Nl ↓ ↓ Nl to ↓ Nl Nl Nl Nl Nl Nl Nl Nl Nl Nl Nl or ↑ Nl ↓ − − Clinical manifestation
  • Not applicable
Amphotericin B[16] − − + − + + − + ↓ + ↓ ↓ ↓ Nl to ↓ Nl Nl Nl Nl Nl Nl Nl Nl Nl Nl ↑ ↑ ↓ − − Clinical manifestation
  • Not applicable
Carbon monoxide poisoning[17] + − + − ± − − + Nl − ↓↓ ↓ ↓ Nl to ↓ Nl Nl Nl Nl Nl Nl Nl ↑ ↑ Nl Nl Nl ↓ − − Clinical manifestation
  • Not applicable
Cyanide poisoning[18] + − − − + − − + ↓ ± ↓↓ ↓ ↓ ↓ Nl to ↑ ↓ Nl Nl Nl Nl Nl ↑ ↑ Nl Nl or ↑ Nl ↓ − − Blood cyanide concentration
  • Not applicable
Category Disease ↑ acid
production 		Loss of
bicarbonate 		↓ renal acid
excretion 		Fever N/V Diarrhea Dyspnea Toxic/ill BP Dehydration Level of consciousness HCO3− paCO2 O2 WBC Hb BS Cl− K+ Na+ Ketones Lactic acid Serum AG Osmolar gap Bun Cr Urine pH Urine AG Urine ketone Gold standard diagnosis Other findings
Ketoacidosis Diabetic ketoacidosis[19] + − − + + + + + ↓ + ↓ ↓ ↓ Nl to ↓ ↑ Nl to ↑ ↑↑ Nl ↑ ↓ ↑ ↑ ↑ ↑ Nl to ↑ Nl ↓ + + Clinical + hyperglycemia + ketosis
  • Labs might show elevated K+ even in K+ depletion due to extravasation of intracellular K+ in exchanged with extracellular H+
Starvation[20] + − − − + − − + ↓ + ↓ ↓ ↓ Nl Nl Nl Nl to ↓ Nl ↓ ↓ ↑ Nl ↑ Nl Nl Nl Nl + − Clinical manifestation
Alcoholic ketoacidosis (Ethanol)[21] + − − − + ± − + ↓ ↑ + Agitated ↓ ↓ ↓ Nl to ↑ Nl to ↑ ↓ Nl ↑ Nl ↓ ↓ ↑↑ ↑ ↑ ↑↑ ↑ Nl ↓ + + Clinical manifestation + ketosis
Systemic Sepsis[22] + − − + + − + + ↓ ↑ + ↓ ↓ ↓ Nl to ↓ ↑ Nl Nl Nl ↑ ↓ Nl Nl to ↑ Nl Nl ↑ ↑ Nl − − Clinical manifestation and lab finding
  • Not applicable
Ischemia[23] + − − − + − + + ↓ + − ↓ ↓ ↑ Nl to ↓ Nl to ↑ Nl Nl Nl ↑ ↓ Nl Nl to ↑ Nl Nl Nl to ↑ Nl to ↑ Nl − − Clinical manifestation and lab finding
  • Not applicable
Lactic acidosis[24] + − − ± + − − + ↓ ↑ ± Agitated ↓ ↓ ↓ Nl to ↑ ↓ Nl Nl Nl Nl Nl ↑ ↑ ↑ Nl or ↑ Nl ↓ − − Clinical manifestation and lab finding
  • Not applicable
Renal Uremia[25] − − + + + − − + ↓ ↑ ± ↓ ↓ ↓ Nl to ↓ ↑ ↓ Nl Nl ↑ ↑ Nl Nl ↑ ↑ ↑ ↑ ↓ + − Clinical manifestation and lab finding
Renal failure[26] − − + − + − − + ↓ + ↓ ↓ ↓ Nl to ↓ ↑ ↓ Nl ↑ ↑ ↓ Nl Nl ↑ ↑ ↑ ↑ ↓ − − Renal function test
  • Not applicable
Renal tubular acidosis[27] Type I[28] − − + ± ± − − − ↓ ↑ − − ↓ ↓ Nl Nl Nl Nl ↑ ↓ ↓ Nl Nl Nl Nl ↑ ↑ ↑ + − Clinical manifestation and lab finding
Type II − + − ± ± − − − ↓ ↑ − − ↓ ↓ Nl Nl Nl Nl ↑ ↓ Nl Nl Nl Nl Nl Nl Nl Nl − − Clinical manifestation and lab finding
  • Not applicable
Type IV − − + ± ± ± − − ↓ − − ↓ ↓ Nl Nl Nl Nl ↑ ↑ Nl Nl Nl Nl Nl Nl Nl Nl + − Clinical manifestation and lab finding
Category Disease ↑ acid
production 		Loss of
bicarbonate 		↓ renal acid
excretion 		Fever N/V Diarrhea Dyspnea Toxic/ill BP Dehydration Level of consciousness HCO3− paCO2 O2 WBC Hb BS Cl− K+ Na+ Ketones Lactic acid Serum AG Osmolar gap Bun Cr Urine pH Urine AG Urine ketone Gold standard diagnosis Other findings
Heart Heart failure[29] + + − − ± − + + ↓ ↑ + − ↓ ↓ ↑ ↓ Nl Nl Nl Nl ↓ ↓ Nl Nl Nl Nl Nl to ↑ Nl to ↑ Nl − − Clinical manifestation+ echocardiogram
Myocardial infarction[30] + − − − + − + + ↓ ↑ − ↓ ↓ ↓ ↑ Nl to ↓ Nl to ↑ Nl Nl Nl ↑ ↓ Nl ↑ Nl Nl Nl to ↑ Nl to ↑ Nl − − Clinical manifestation + ECG
  • Not applicable
GI Diarrhea[31] − + − ± + + − + ↓ + May be lethargic ↓ ↓ Nl Nl ↓ ↓ ↑ ↑ Nl Nl Nl Nl Nl ↑ Nl Nl − − Stool exam
  • Not applicable
Hyperalimentation[32] + + − − − + − − Nl − − ↓ ↓ Nl Nl ↓ Nl ↑ ↑ Nl Nl Nl Nl Nl Nl Nl Nl − − Clinical manifestation
  • Not applicable
Liver failure[33] − + − − + + − + ↓ + Confused ↓ ↓ Nl Nl ↓ ↓ ↑ ↑ ↓ ↓ Nl Nl Nl Nl Nl Nl Nl − − Liver biopsy
  • Not applicable
Endocrine Hyperparathyroidism[34] − + + − + − − − Nl + Confused ↓ ↓ Nl Nl Nl Nl Nl Nl Nl Nl Nl Nl Nl Nl to ↑ Nl Nl − − PTH level
  • Not applicable
Addison's disease[35] − + − − + + − − ↓ + Irritable ↓ ↓ Nl Nl Nl ↓ Nl ↑ ↓ Nl Nl Nl Nl Nl Nl Nl − − Hormone level
Category Disease ↑ acid
production 		Loss of
bicarbonate 		↓ renal acid
excretion 		Fever N/V Diarrhea Dyspnea Toxic/ill BP Dehydration Level of consciousness HCO3− paCO2 O2 WBC Hb BS Cl− K+ Na+ Ketones Lactic acid Serum AG Osmolar gap Bun Cr Urine pH Urine AG Urine ketone Gold standard diagnosis Other findings

References

  1. ↑ Lim S (2007). "Metabolic acidosis". Acta Med Indones. 39 (3): 145–50. PMID 17936961.
  2. ↑ Morris, C. G.; Low, J. (2008). "Metabolic acidosis in the critically ill: Part 1. Classification and pathophysiology". Anaesthesia. 63 (3): 294–301. doi:10.1111/j.1365-2044.2007.05370.x. ISSN 0003-2409.
  3. ↑ Morris CG, Low J (April 2008). "Metabolic acidosis in the critically ill: part 2. Causes and treatment". Anaesthesia. 63 (4): 396–411. doi:10.1111/j.1365-2044.2007.05371.x. PMID 18336491.
  4. ↑ Casaletto, Jennifer J. (2005). "Differential Diagnosis of Metabolic Acidosis". Emergency Medicine Clinics of North America. 23 (3): 771–787. doi:10.1016/j.emc.2005.03.007. ISSN 0733-8627.
  5. ↑ Brubaker RH, Meseeha M. High Anion Gap Metabolic Acidosis. [Updated 2017 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448090/
  6. ↑ Kraut JA, Xing SX (September 2011). "Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis". Am. J. Kidney Dis. 58 (3): 480–4. doi:10.1053/j.ajkd.2011.05.018. PMID 21794966.
  7. ↑ Pham, Amy Quynh Trang; Xu, Li Hao Richie; Moe, Orson W. (2015). "Drug-Induced Metabolic Acidosis". F1000Research. doi:10.12688/f1000research.7006.1. ISSN 2046-1402.
  8. ↑ Zehtabchi S, Sinert R, Baron BJ, Paladino L, Yadav K (2005). "Does ethanol explain the acidosis commonly seen in ethanol-intoxicated patients?". Clin Toxicol (Phila). 43 (3): 161–6. PMID 15902789.
  9. ↑ Roberts, Darren M.; Yates, Christopher; Megarbane, Bruno; Winchester, James F.; Maclaren, Robert; Gosselin, Sophie; Nolin, Thomas D.; Lavergne, Valéry; Hoffman, Robert S.; Ghannoum, Marc (2015). "Recommendations for the Role of Extracorporeal Treatments in the Management of Acute Methanol Poisoning". Critical Care Medicine. 43 (2): 461–472. doi:10.1097/CCM.0000000000000708. ISSN 0090-3493.
  10. ↑ Ashurst JV, Nappe TM. Toxicity, Isopropanol. [Updated 2018 Mar 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493181/
  11. ↑ Camara-Lemarroy, Carlos Rodrigo; Rodríguez-Gutiérrez, René; Monreal-Robles, Roberto; González-González, José Gerardo (2015). "Acute toluene intoxication–clinical presentation, management and prognosis: a prospective observational study". BMC Emergency Medicine. 15 (1). doi:10.1186/s12873-015-0039-0. ISSN 1471-227X.
  12. ↑ Wright, Dallas; Sop, Jessica (2015). "Normal anion gap salicylate poisoning". The American Journal of Emergency Medicine. 33 (11): 1714.e3–1714.e4. doi:10.1016/j.ajem.2015.03.042. ISSN 0735-6757.
  13. ↑ Galiero, Francesca; Consani, Giovanni; Biancofiore, Gianni; Ruschi, Stefano; Forfori, Francesco (2018). "Metformin intoxication: Vasopressin's key role in the management of severe lactic acidosis". The American Journal of Emergency Medicine. 36 (2): 341.e5–341.e6. doi:10.1016/j.ajem.2017.10.057. ISSN 0735-6757.
  14. ↑ Watkins RC, Hambrick EL, Benjamin G, Chavda SN (January 1990). "Isoniazid toxicity presenting as seizures and metabolic acidosis". J Natl Med Assoc. 82 (1): 57, 62, 64. PMC 2625939. PMID 2304098.
  15. ↑ Teppema, Luc J.; Balanos, George M.; Steinback, Craig D.; Brown, Allison D.; Foster, Glen E.; Duff, Henry J.; Leigh, Richard; Poulin, Marc J. (2007). "Effects of Acetazolamide on Ventilatory, Cerebrovascular, and Pulmonary Vascular Responses to Hypoxia". American Journal of Respiratory and Critical Care Medicine. 175 (3): 277–281. doi:10.1164/rccm.200608-1199OC. ISSN 1073-449X.
  16. ↑ Bates, D. W.; Su, L.; Yu, D. T.; Chertow, G. M.; Seger, D. L.; Gomes, D. R. J.; Dasbach, E. J.; Platt, R. (2001). "Mortality and Costs of Acute Renal Failure Associated with Amphotericin B Therapy". Clinical Infectious Diseases. 32 (5): 686–693. doi:10.1086/319211. ISSN 1058-4838.
  17. ↑ Piantadosi CA (June 1999). "Diagnosis and treatment of carbon monoxide poisoning". Respir Care Clin N Am. 5 (2): 183–202. PMID 10333448.
  18. ↑ Baud FJ, Borron SW, Mégarbane B, Trout H, Lapostolle F, Vicaut E, Debray M, Bismuth C (September 2002). "Value of lactic acidosis in the assessment of the severity of acute cyanide poisoning". Crit. Care Med. 30 (9): 2044–50. doi:10.1097/01.CCM.0000026325.65944.7D. PMID 12352039.
  19. ↑ Wolfsdorf, Joseph I; Allgrove, Jeremy; Craig, Maria E; Edge, Julie; Glaser, Nicole; Jain, Vandana; Lee, Warren WR; Mungai, Lucy NW; Rosenbloom, Arlan L; Sperling, Mark A; Hanas, Ragnar (2014). "Diabetic ketoacidosis and hyperglycemic hyperosmolar state". Pediatric Diabetes. 15 (S20): 154–179. doi:10.1111/pedi.12165. ISSN 1399-543X.
  20. ↑ Mostert M, Bonavia A (October 2016). "Starvation Ketoacidosis as a Cause of Unexplained Metabolic Acidosis in the Perioperative Period". Am J Case Rep. 17: 755–758. PMC 5070574. PMID 27752032.
  21. ↑ Howard RD, Bokhari S. PMID 28613672. Vancouver style error: initials (help); Missing or empty |title= (help)
  22. ↑ Ganesh K, Sharma RN, Varghese J, Pillai MG (2016). "A profile of metabolic acidosis in patients with sepsis in an Intensive Care Unit setting". Int J Crit Illn Inj Sci. 6 (4): 178–181. doi:10.4103/2229-5151.195417. PMC 5225760. PMID 28149822.
  23. ↑ Kimmoun, Antoine; Novy, Emmanuel; Auchet, Thomas; Ducrocq, Nicolas; Levy, Bruno (2015). "Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside". Critical Care. 19 (1). doi:10.1186/s13054-015-0896-7. ISSN 1364-8535.
  24. ↑ Kraut, Jeffrey A.; Ingelfinger, Julie R.; Madias, Nicolaos E. (2014). "Lactic Acidosis". New England Journal of Medicine. 371 (24): 2309–2319. doi:10.1056/NEJMra1309483. ISSN 0028-4793.
  25. ↑ Brown, Denver; Melamed, Michal L. (2018). "New Frontiers in Treating Uremic Metabolic Acidosis". Clinical Journal of the American Society of Nephrology. 13 (1): 4–5. doi:10.2215/CJN.11771017. ISSN 1555-9041.
  26. ↑ Kraut, Jeffrey A.; Madias, Nicolaos E. (2016). "Metabolic Acidosis of CKD: An Update". American Journal of Kidney Diseases. 67 (2): 307–317. doi:10.1053/j.ajkd.2015.08.028. ISSN 0272-6386.
  27. ↑ Gil-Peña, Helena; Mejía, Natalia; Santos, Fernando (2014). "Renal Tubular Acidosis". The Journal of Pediatrics. 164 (4): 691–698.e1. doi:10.1016/j.jpeds.2013.10.085. ISSN 0022-3476.
  28. ↑ Hemstreet, Brian A (2004). "Antimicrobial-Associated Renal Tubular Acidosis". Annals of Pharmacotherapy. 38 (6): 1031–1038. doi:10.1345/aph.1D573. ISSN 1060-0280.
  29. ↑ Park, Jin Joo; Choi, Dong-Ju; Yoon, Chang-Hwan; Oh, Il-Young; Lee, Ju Hyun; Ahn, Soyeon; Yoo, Byung-Su; Kang, Seok-Min; Kim, Jae-Joong; Baek, Sang-Hong; Cho, Myeong-Chan; Jeon, Eun-Seok; Chae, Shung Chull; Ryu, Kyu-Hyung; Oh, Byung-Hee (2015). "The prognostic value of arterial blood gas analysis in high-risk acute heart failure patients: an analysis of the Korean Heart Failure (KorHF) registry". European Journal of Heart Failure. 17 (6): 601–611. doi:10.1002/ejhf.276. ISSN 1388-9842.
  30. ↑ Mann, Sarah; Bajulaiye, Akinyemi; Sturgeon, Kathleen; Sabri, Abdelkarim; Muthukumaran, Geetha; Libonati, Joseph R. (2014). "Effects of acute angiotensin II on ischemia reperfusion injury following myocardial infarction". Journal of the Renin-Angiotensin-Aldosterone System. 16 (1): 13–22. doi:10.1177/1470320314554963. ISSN 1470-3203.
  31. ↑ Guerrant, R. L.; Van Gilder, T.; Steiner, T. S.; Thielman, N. M.; Slutsker, L.; Tauxe, R. V.; Hennessy, T.; Griffin, P. M.; DuPont, H.; Bradley Sack, R.; Tarr, P.; Neill, M.; Nachamkin, I.; Reller, L. B.; Osterholm, M. T.; Bennish, M. L.; Pickering, L. K. (2001). "Practice Guidelines for the Management of Infectious Diarrhea". Clinical Infectious Diseases. 32 (3): 331–351. doi:10.1086/318514. ISSN 1058-4838.
  32. ↑ Erlingsson, Styrbjörn; Herard, Sebastian; Dahlqvist Leinhard, Olof; Lindström, Torbjörb; Länne, Toste; Borga, Magnus; Nystrom, Fredrik H. (2009). "Men develop more intraabdominal obesity and signs of the metabolic syndrome after hyperalimentation than women". Metabolism. 58 (7): 995–1001. doi:10.1016/j.metabol.2009.02.028. ISSN 0026-0495.
  33. ↑ Lange, Christian M.; Bojunga, Jörg; Hofmann, Wolf Peter; Wunder, Katrin; Mihm, Ulrike; Zeuzem, Stefan; Sarrazin, Christoph (2009). "Severe lactic acidosis during treatment of chronic hepatitis B with entecavir in patients with impaired liver function". Hepatology. 50 (6): 2001–2006. doi:10.1002/hep.23346. ISSN 0270-9139.
  34. ↑ Bilezikian, John P.; Potts, John T.; Fuleihan, Ghada El-Hajj; Kleerekoper, Michael; Neer, Robert; Peacock, Munro; Rastad, Jonas; Silverberg, Shonni J.; Udelsman, Robert; Wells, Samuel A. (2002). "Summary Statement from a Workshop on Asymptomatic Primary Hyperparathyroidism: A Perspective for the 21st Century". The Journal of Clinical Endocrinology & Metabolism. 87 (12): 5353–5361. doi:10.1210/jc.2002-021370. ISSN 0021-972X.
  35. ↑ Ten, Svetlana; New, Maria; Maclaren, Noel (2001). "Addison's Disease 2001". The Journal of Clinical Endocrinology & Metabolism. 86 (7): 2909–2922. doi:10.1210/jcem.86.7.7636. ISSN 0021-972X.
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