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| {{CMG}}; {{AE}} {{ADS}} | | {{CMG}}; {{AE}} {{ADS}} |
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| ==Adrenal Insufficiency==
| |
|
| |
| {| class="wikitable"
| |
| ! rowspan="3" |Acute/
| |
| Chronic
| |
| ! rowspan="2" |Disease
| |
| ! colspan="7" |Clinical history/findings
| |
| ! rowspan="2" |Causes
| |
| ! colspan="4" |Laboratory findings
| |
| ! rowspan="2" |Medical therapy
| |
| |-
| |
| !Hypotension
| |
| !Skin
| |
| pigmentation/
| |
|
| |
| findings
| |
| !Fatigue
| |
| !Anorexia/
| |
| weightloss
| |
| !Abdominal pain
| |
| !Muscle
| |
| weakness
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| !Other history/
| |
| findings
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| !Hypo
| |
| natremia
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| !Cortisol levels
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| !Gold Standard
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| !Other
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| |-
| |
| ! colspan="14" |<big>Differentiating amongst adrenal insufficiencies</big>
| |
| |-
| |
| |Chronic
| |
| |'''[[Primary adrenal insufficiency|Primary adrenal]]'''
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| '''[[Primary adrenal insufficiency|insufficiency]]/ [[Addison's disease]]'''
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| |
| |
| * [[Nausea and vomiting|Nausea and Vomiting]]
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| * [[Hypoglycemia]]
| |
| |
| |
| *Autoimmune/idiopathic
| |
| *Infections- [[Tuberculosis]]<ref name="pmid18591375">{{cite journal |vauthors=Patnaik MM, Deshpande AK |title=Diagnosis--Addison's disease secondary to tuberculosis of the adrenal glands |journal=Clin Med Res |volume=6 |issue=1 |pages=29 |year=2008 |pmid=18591375 |pmc=2442022 |doi=10.3121/cmr.2007.754a |url=}}</ref><ref name="pmid24772716">{{cite journal |vauthors=Bhattacharjee R, Sharma A, Rays A, Thakur I, Sarkar D, Mandal B, Mookerjee SK, Chatterjee SK, Chowdhury PR |title=Addison's disease presenting with muscle spasm |journal=J Assoc Physicians India |volume=61 |issue=9 |pages=675–6 |year=2013 |pmid=24772716 |doi= |url=}}</ref>, [[histoplasmosis]]<ref name="pmid27727656">{{cite journal |vauthors=Ray A, Sanyal D |title=A rare case of Addison's disease due to bilateral adrenal histoplasmosis presenting with hypoglycaemia |journal=J Assoc Physicians India |volume=64 |issue=1 |pages=45–46 |year=2016 |pmid=27727656 |doi= |url=}}</ref><ref name="pmid24194970">{{cite journal |vauthors=Choudhary N, Aggarwal I, Dutta D, Ghosh AG, Chatterjee G, Chowdhury S |title=Acquired perforating dermatosis and Addison's disease due to disseminated histoplasmosis: Presentation and clinical outcomes |journal=Dermatoendocrinol |volume=5 |issue=2 |pages=305–8 |year=2013 |pmid=24194970 |pmc=3772918 |doi=10.4161/derm.22677 |url=}}</ref>
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| |Low
| |
| |[[Cosyntropin]]/ [[ACTH stimulation test|ACTH stimulation tes]]<nowiki/>t
| |
| |
| |
| * [[Hyperkalemia]]
| |
| |
| |
| * [[Hydrocortisone]] -15 to 25 mg PO q daily in 2 to 3 divided doses
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| * [[Fludrocortisone]] - 0.1 to 0.2 mg PO q daily
| |
| |-
| |
| |Chronic
| |
| |'''Secondary adrenal'''
| |
| '''insufficiency'''
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |±
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | –
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |±
| |
| |
| |
| * [[Hypoglycemia]] (more than primary adrenal insufficiency)
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| * Signs of pituitary tumor- [[headache]], visual field defects ([[bitemporal hemianopsia]])
| |
| |
| |
| * [[Hypopituitarism]]- Tumors, infections, hemorrhage/trauma
| |
| * Drugs- Chronic [[steroid]] therapy and its withdrawal, [[opiates]]<ref name="pmid19373753">{{cite journal |vauthors=Schimke KE, Greminger P, Brändle M |title=Secondary adrenal insufficiency due to opiate therapy - another differential diagnosis worth consideration |journal=Exp. Clin. Endocrinol. Diabetes |volume=117 |issue=10 |pages=649–51 |year=2009 |pmid=19373753 |doi=10.1055/s-0029-1202851 |url=}}</ref>
| |
| * [[Genetics|Genetic]]- Combined pituitary hormone deficiency (CPHD), [[POMC]] ([[proopiomelanocortin]]) gene deficiency
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| |Normal
| |
| |[[Cosyntropin]]/ [[ACTH stimulation test|ACTH stimulation tes]]<nowiki/>t
| |
| |
| |
| * 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]]'''
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | ++
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | ±
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | ±
| |
| |
| |
| * Signs of shock
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| * [[Altered mental status]]/ [[Loss of consciousness]]/ [[Coma]]
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| * [[Fever]]
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| * [[Nausea and vomiting|Nausea]]/ [[Nausea and vomiting|vomiting]]
| |
| |
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| * [[Infection]]
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| * [[Trauma]]
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| * [[Surgery]]
| |
| * [[Anesthesia]] ([[etomidate]])
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| |Normal to Low
| |
| |[[Cosyntropin]]/ [[ACTH stimulation test|ACTH stimulation tes]]<nowiki/>t
| |
| |
| |
| * [[ECG]] (electrocardiogram)
| |
| * [[CBC]] (complete blood count)
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| * [[BUN]] (blood urea nitrogen)
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| * [[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
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| * [[Fludrocortisone]] - 0.1 to 0.2 mg PO q daily after initial stabilization
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| |-
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| ! colspan="15" |'''<big>Differentiating Adrenal Insufficiency from other diseases</big>'''
| |
| |-
| |
| |
| |
| |'''[[Adrenal hemorrhage]]/ Waterhouse Friderichsen syndrome'''
| |
| |orthostatic
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | ±
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | ±
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | –
| |
| |
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| * [[Fever]]
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| * [[Tachycardia]]
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| * [[Dizziness]]
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| * [[Nausea and vomiting|Nausea]]/ [[Nausea and vomiting|vomiting]]
| |
| * [[Diarrhea]]
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| |
| |
| * Infection
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| # Sepsis- [[pneumonia]]
| |
| # Waterhouse Friderichsen syndrome- [[meningococcemia]]
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| * Cardiac- [[Congestive heart failure]] (CHF), [[myocardial infarction]]
| |
| * Gastrointestinal- [[Acute pancreatitis|Acute pancreatitis,]] [[cirrhosis]]
| |
| * Bleeding situations- [[Spontaneous abortions]], [[thrombocytopenia]], [[anticoagulants]] use, [[surgery]], [[heparin-induced thrombocytopenia]]
| |
| * Trauma
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| * Thrombotic phenomenon- [[pulmonary embolus]], [[deep venous thrombosis]], [[antiphospholipid antibody syndrome]]
| |
| * Tumors- Adrenal adenomas, [[pheochromocytoma]]
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| |Normal to low
| |
| |[[Cosyntropin]]/ [[ACTH stimulation test|ACTH stimulation tes]]<nowiki/>t
| |
| |
| |
| * [[CBC]] (Complete blood count)
| |
| * CT scan
| |
| |
| |
| * Stabilize the patient
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| * Treat the underlying cause
| |
| |-
| |
| |
| |
| |'''[[Congenital Adrenal Hyperplasia|Congenital adrenal hyperplasia]] (CAH)'''
| |
| |Normal to hypertension
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |±
| |
| (can be indicator of Uncontrolled CAH)<ref name="pmid27072733">{{cite journal |vauthors=Patel FB, Newman SA, Norton SA |title=Addisonian-Like Hyperpigmentation as an Indicator of Uncontrolled Congenital Adrenal Hyperplasia |journal=Skinmed |volume=14 |issue=1 |pages=53–4 |year=2016 |pmid=27072733 |doi= |url=}}</ref>
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| |
| |
| * Female- [[Ambiguous genitalia]]/ [[virilization]], [[infertility]]
| |
| * Male- Normal or enlarged [[Phallus (embryology)|phallus]]
| |
| * [[Short stature]]
| |
| |
| |
| * [[21-hydroxylase deficiency|21-hydroxylase deficiency]]
| |
| * 17α hydroxylase deficiency
| |
| * 11 β hydroxylase deficiency
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |±
| |
| |Low
| |
| |[[Cosyntropin]]/ [[ACTH stimulation test|ACTH stimulation tes]]<nowiki/>t
| |
| |
| |
| * 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]])'''
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| |
| |
| * [[Nausea]]/[[vomiting]]
| |
| * [[Cramps]]
| |
| * [[Depressed mood]]
| |
| * [[Irritability]]
| |
| * [[Confusion]]
| |
| * [[Hallucinations]]
| |
| * [[Seizures]], [[stupor]] or [[coma]]
| |
| |
| |
| * Head trauma-[[subarachnoid hemorrhage]]
| |
| * Tumors- [[Intracerebral metastases|metastasis]]
| |
| * Infections- [[Brain abscess]]
| |
| * Drugs- [[chlorpropamide]], [[cyclophosphamide]], [[carbamazepine]], [[selective serotonin reuptake inhibitors]], [[methylenedioxymethamphetamine]] (MDMA, commonly called [[Ecstasy (drug)|Ecstasy]])
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| |Normal
| |
| |Water deprivation test
| |
| |
| |
| * Decreased [[osmolality]]
| |
| * Euvolemia
| |
| * Sodium in urine typically >20 mEq/
| |
| |
| |
| * Mild- Fluid restriction
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| * Moderate- [[Loop diuretics]]
| |
| * Severe Hypertonic (3%) [[saline]]
| |
| |-
| |
| |
| |
| |'''Salt-depletion nephritis/ Salt losing nephropathy'''
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | –
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | –
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | –
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | + Flank pain
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | –
| |
| |
| |
| * [[Fever]]
| |
| * [[Dysuria]]
| |
| * [[Pyuria]]
| |
| * [[Oliguria]]
| |
| |
| |
| * [[Chronic renal failure]]
| |
| * [[Bartter syndrome]]<ref name="pmid26178649">{{cite journal |vauthors=Seyberth HW |title=Pathophysiology and clinical presentations of salt-losing tubulopathies |journal=Pediatr. Nephrol. |volume=31 |issue=3 |pages=407–18 |year=2016 |pmid=26178649 |doi=10.1007/s00467-015-3143-1 |url=}}</ref>
| |
| * [[Gitelman syndrome]]
| |
| * Drugs- [[Tacrolimus]]<ref name="pmid27500237">{{cite journal |vauthors=Sayin B |title=Tacrolimus-Induced Salt Losing Nephropathy Resolved After Conversion to Everolimus |journal=Transplant Direct |volume=1 |issue=9 |pages=e37 |year=2015 |pmid=27500237 |pmc=4946484 |doi=10.1097/TXD.0000000000000538 |url=}}</ref>
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | ++<ref name="pmid19888422">{{cite journal |vauthors=Yoshioka K, Nishio M, Sano S, Sakurai K, Yamagami K, Yamashita Y |title=Development of Severe Hyponatremia due to Salt-Losing Nephropathy after Esophagectomy for Esophageal Cancer |journal=Case Rep Med |volume=2009 |issue= |pages=241283 |year=2009 |pmid=19888422 |pmc=2771150 |doi=10.1155/2009/241283 |url=}}</ref>
| |
| |High
| |
| |Genetic study
| |
| |<15:1 [[BUN-to-creatinine ratio|BUN:CR]]
| |
| |
| |
| * [[Fludrocortisone]] - 0.05 to 0.2 mg PO q daily
| |
| |-
| |
| |
| |
| |[[Anorexia nervosa]]
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | –
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | –
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" | +
| |
| |
| |
| * Distorted body image
| |
| * [[Hypoglycemia]]
| |
| * [[Amenorrhea|Amenorrhoea]]/ [[Oligomenorrhea|oligomenorrhoea]]
| |
| * [[Osteoporosis]]
| |
| * [[Refeeding syndrome]]
| |
| |
| |
| * Genetic
| |
| * Hormonal- Low [[dopamine]] and [[serotonin]]
| |
| * Psychological
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| |High
| |
| |Psychiatric condition
| |
| | style="background: #F5F5F5; padding: 5px; text-align:center" |–
| |
| |
| |
| * Nutritional replacement
| |
| * Psychotherapy- e.g. [[Cognitive behavioral therapy]]
| |
| * For [[refeeding syndrome]]-hospitalization and replacements of [[potassium]], [[phosphate]] and [[magnesium]]
| |
| |}
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|
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|
| ==References== | | ==References== |
| {{reflist|2}} | | {{reflist|2}} |
| <references /> | | <references /> |