Sandbox:Amd

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

Adrenal Insufficiency

Acute/ Chronic	Disease	Clinical history/findings							Causes	Laboratory findings				Medical therapy
		Hypotension	Skin pigmentation/ findings	Fatigue	Anorexia/ weightloss	Abdominal pain	Muscle weakness	Other history/ findings		Hypo natremia	Cortisol levels	Gold Standard	Other
	Differentiating amongst adrenal insufficiencies
Chronic	Primary adrenal insufficiency/ Addison's disease	+	+	+	+	+	+	Nausea and Vomiting Hypoglycemia	Autoimmune/idiopathic Infections- Tuberculosis, histoplasmosis	+	Low	Cosyntropin/ ACTH stimulation test	Hyperkalemia	Hydrocortisone -15 to 25 mg PO q daily in 2 to 3 divided doses Fludrocortisone - 0.1 to 0.2 mg PO q daily
Chronic	Secondary adrenal insufficiency	±	–	+	+	–	±	Hypoglycemia (more than primary adrenal insufficiency) Signs of pituitary tumor- headache, visual field defects (bitemporal hemianopsia)	Hypopituitarism- Tumors, infections, hemorrhage/trauma Drugs- Chronic steroid therapy and its withdrawal, opiates Genetic- Combined pituitary hormone deficiency (CPHD), POMC (proopiomelanocortin) gene deficiency	–	Normal	Cosyntropin/ ACTH stimulation test	CT scan/ MRI scan showing pituitary causes	Hydrocortisone -15 to 25 mg PO daily in 2 to 3 divided doses
Acute	Acute adrenal insufficiency/ Acute adrenal crisis	++	±	+	+	+	±	Signs of shock Altered mental status/ Loss of consciousness/ Coma Fever Nausea/ vomiting	Infection Trauma Surgery Anesthesia (etomidate)	+	Normal to Low	Cosyntropin/ ACTH stimulation test	ECG (electrocardiogram) CBC (complete blood count) BUN (blood urea nitrogen) Creatinine	I/V 0.9% saline 1-3 liters within 12-24 hours I/V Dexamethasone 4 mg bolus, or, I/V hydrocortisone 50 mg bolus Fludrocortisone - 0.1 to 0.2 mg PO q daily after initial stabilization
Differentiating Adrenal Insufficiency from other diseases
	Adrenal hemorrhage/ Waterhouse Friderichsen syndrome	orthostatic	±	+	±	+	–	Fever Tachycardia Dizziness Nausea/ vomiting Diarrhea	Infection Sepsis- pneumonia Waterhouse Friderichsen syndrome- meningococcemia Cardiac- Congestive heart failure (CHF), myocardial infarction Gastrointestinal- Acute pancreatitis, cirrhosis Bleeding situations- Spontaneous abortions, thrombocytopenia, anticoagulants use, surgery, heparin-induced thrombocytopenia Trauma Thrombotic phenomenon- pulmonary embolus, deep venous thrombosis, antiphospholipid antibody syndrome Tumors- Adrenal adenomas, pheochromocytoma	+	Normal to low	Cosyntropin/ ACTH stimulation test	CBC (Complete blood count) CT scan	Stabilize the patient Treat the underlying cause
	Congenital adrenal hyperplasia (CAH)	Normal to hypertension	± (can be indicator of Uncontrolled CAH)	–	–	–	–	Female- Ambiguous genitalia/ virilization, infertility Male- Normal or enlarged phallus Short stature	21-hydroxylase deficiency 17α hydroxylase deficiency 11 β hydroxylase deficiency	±	Low	Cosyntropin/ ACTH stimulation test	Serum 17-hydroxyprogesterone Hyperkalemia	Hydrocortisone -15 to 25 mg PO daily in 2 to 3 divided doses Fludrocortisone - 0.1 to 0.2 mg PO q daily
	Syndrome of inappropriate antidiuretic hormone (SIADH)	–	–	–	–	–	–	Nausea/vomiting Cramps Depressed mood Irritability Confusion Hallucinations Seizures, stupor or coma	Head trauma-subarachnoid hemorrhage Tumors- metastasis Infections- Brain abscess Drugs- chlorpropamide, cyclophosphamide, carbamazepine, selective serotonin reuptake inhibitors, methylenedioxymethamphetamine (MDMA, commonly called Ecstasy)	+	Normal	Water deprivation test	Decreased osmolality Euvolemia Sodium in urine typically >20 mEq/	Mild- Fluid restriction Moderate- Loop diuretics Severe Hypertonic (3%) saline
	Salt-depletion nephritis/ Salt losing nephropathy	+	–	–	–	+ Flank pain	–	Fever Dysuria Pyuria Oliguria	Chronic renal failure Bartter syndrome Gitelman syndrome	+	HIgh	Genetic study	<15:1 BUN:CR	Fludrocortisone - 0.05 to 0.2 mg PO q daily
	Anorexia nervosa	+	–	+	+	–	+	Distorted body image Hypoglycemia Amenorrhoea/ oligomenorrhoea Osteoporosis Refeeding syndrome	Genetic Hormonal- Low dopamine and serotonin Psychological	–	High	Psychiatric condition	–	Nutritional replacement Psychotherapy- e.g. Cognitive behavioral therapy For refeeding syndrome-hospitalization and replacements of potassium, phosphate and magnesium