Secondary adrenal insufficiency causes: Difference between revisions

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Revision as of 14:08, 16 October 2017

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

Overview

Secondary adrenal insufficiency is caused mainly by 4 categories, hypopituitarism, drugs, genetic and other causes. Life-threatening causes include acute withdrawal of steroids, adrenal hemorrhage, Waterhouse-Friderichson syndrome, anticoagulation and gastroenteritis which causes adrenal crisis. The common causes include chronic steroid therapy and its withdrawal, opiates, causes of panhypopituitarism and the less common causes are genetic causes which include combined pituitary hormone deficiency (CPHD), proopiomelanocortin deficiency POMC and isolated ACTH deficiency.

Causes

Life-threatening Causes

Life-threatening causes of secondary adrenal insufficiency include causes of acute adrenal crisis/insufficiency:

Acute withdrawal of steroids.
Traumatic hypopituitarism.^[1]
Adrenal hemorrhage
- Waterhouse-Friderichson syndrome
- Anticoagulation.
Gastroenteritis.^[2]

Common Causes

Secondary adrenal insufficiency may be caused by:

Drugs
- Chronic steroid therapy and its withdrawal
- Opiates
- Etomidate
- Antifungals- ketoconazole^[3]
Pituitary causes:
- Infections- tuberculosis
- Pituitary infarction
  - Pituitary apoplexy
  - Sheehan's syndrome
- Pituitary removal
- Pituitary irradiation

Less Common Causes

Less common causes of secondary adrenal insufficiency include:

Pituitary causes
- Lymphocytic hypophysitis
- Tumors- craniopharyngioma, metastasis,

Genetic causes:
- Combined pituitary hormone deficiency (CPHD)
- Proopiomelanocortin deficiency (POMC)
- Isolated ACTH deficiency

Causes by Organ System

Cardiovascular	Arteritis, Hypotension, Hemorrhage, Infarction
Chemical / poisoning	No underlying causes
Dermatologic	POEMS syndrome
Drug Side Effect	Aminoglutethimide, Ciclesonide, Cidofovir, Corticosteroid withdrawal, Dexamethasone, Flunisolide, Pembrolizumab,prednisolone, Trilostane
Ear Nose Throat	No underlying causes
Endocrine	Allgrove syndrome, Achalasia-addisonian syndrome, Adrenal aplasia / adrenal 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
Environmental	No underlying causes
Gastroenterologic	Allgrove syndrome, Achalasia-addisonian syndrome, Hemochromatosis
Genetic	Congenital adrenal hyperplasia, Cytochrome P450 oxidoreductase deficiency, Glycerol kinase deficiency, Hereditary ACTH resistance, IMAGE syndrome, X-linked adrenal hypoplasia congenita, Combined pituitary hormone deficiency (CPHD), Proopiomelanocortin deficiency (POMC), Isolated ACTH deficiency
Hematologic	Anticoagulation, Coagulopathy , Embolus, Leukemia, Lymphoma , Thrombosis
Iatrogenic	Iatrogenic, Radiation therapy, Chronic steroid therapy
Infectious Disease	AIDS, Blastomycosis, CMV, Coccidiomycosis, Cryptococcosis, Histoplasmosis , Mycobacterium avium intracellulaire (MAI), Sepsis, Syphilis, Toxoplasmosis, Tuberculosis, Waterhouse-Friderichson syndrome
Musculoskeletal / Ortho	IMAGE syndrome
Neurologic	Adrenoleukodystrophy, Coma, Craniopharyngioma, Panhypopituitarism, POEMS syndrome
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	Craniopharyngioma, Kaposi's sarcoma, Leukemia, Lymphoma , pituitary metastasis
Ophthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	Sarcoidosis,
Renal / Electrolyte	Uremia, Waterhouse-Friderichson syndrome
Rheum / Immune / Allergy	Autoimmune, Autoimmune polyendocrine syndrome type 2, Sarcoidosis
Sexual	No underlying causes
Trauma	Trauma
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Amyloidosis, Idiopathic, Iatrogenic, Radiation therapy, Surgery, Surgical removal of pituitary, Surgical removal of hypothalamus

Causes in Alphabetical Order

Achalasia-addisonian syndrome^[4]
Adrenal aplasia / Adrenal hypoplasia
Adrenal metastases
Adrenoleukodystrophy^[5]
After surgery of cortisol-secreting tumor
AIDS^[6]^[7]
Allgrove syndrome^[4]
Aminoglutethimide
Amyloidosis
Anticoagulation
Arteritis
Autoimmune
Autoimmune polyendocrine syndrome type 2^[8]
Bilateral adrenalectomy
Blastomycosis^[9]
CMV^[10]
Coagulopathy
Coccidiomycosis
Coma
Combined pituitary hormone deficiency (CPHD)
Congenital adrenal hyperplasia
Corticosteroid withdrawal
Craniopharyngioma^[11]
Cryptococcosis^[12]
Cytochrome P450 oxidoreductase deficiency
Embolus
Flunisolide
Glucocorticoid deficiency 1^[13]
Glycerol kinase deficiency^[14]
Hemochromatosis^[15]

Hemorrhage
Hereditary ACTH resistance
Histoplasmosis
Hypotension
Iatrogenic
Idiopathic
IMAGE syndrome^[16]
Infarction
Isolated ACTH deficiency
Kaposi's sarcoma
Leukemia
Lymphoma
Metastasis
Mycobacterium avium intracellulaire (MAI)^[17]
Panhypopituitarism
POEMS syndrome^[18]
Proopiomelanocortin deficiency (POMC)
Radiation therapy
Sarcoidosis^[19]
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

References

↑ Ham PB, Cunningham AJ, Mentzer CJ, Ahmad A, Young LS, Abuzeid AM (2015). "Traumatic panhypopituitarism resulting in acute adrenal crisis". J Trauma Acute Care Surg. 79 (3): 484–9. doi:10.1097/TA.0000000000000771. PMID 26307884.
↑ Puar TH, Stikkelbroeck NM, Smans LC, Zelissen PM, Hermus AR (2016). "Adrenal Crisis: Still a Deadly Event in the 21st Century". Am J Med. 129 (3): 339.e1–9. doi:10.1016/j.amjmed.2015.08.021. PMID 26363354.
↑ "www.ucdenver.edu" (PDF).
↑ ^4.0 ^4.1 Huebner A, Yoon SJ, Ozkinay F; et al. (2000). "Triple A syndrome--clinical aspects and molecular genetics". Endocr. Res. 26 (4): 751–9. PMID 11196451. Unknown parameter |month= ignored (help)
↑ Mosser J, Douar AM, Sarde CO; et al. (1993). "Putative X-linked adrenoleukodystrophy gene shares unexpected homology with ABC transporters". Nature. 361 (6414): 726–30. doi:10.1038/361726a0. PMID 8441467. Unknown parameter |month= ignored (help)
↑ Shashidhar PK, Shashikala GV (2012). "Low dose adrenocorticotropic hormone test and adrenal insufficiency in critically ill acquired immunodeficiency syndrome patients". Indian J Endocrinol Metab. 16 (3): 389–94. doi:10.4103/2230-8210.95680. PMC 3354846. PMID 22629505. Unknown parameter |month= ignored (help)
↑ Eledrisi MS, Verghese AC (2001). "Adrenal insufficiency in HIV infection: a review and recommendations". Am. J. Med. Sci. 321 (2): 137–44. PMID 11217816. Unknown parameter |month= ignored (help)
↑ Cocco C, Meloni A, Mariotti S; et al. (2012). "Novel neuronal and endocrine autoantibody targets in autoimmune polyendocrine syndrome type 1". Autoimmunity. 45 (6): 485–94. doi:10.3109/08916934.2012.680632. PMID 22506635. Unknown parameter |month= ignored (help)
↑ Osa SR, Peterson RE, Roberts RB (1981). "Recovery of adrenal reserve following treatment of disseminated South American blastomycosis". Am. J. Med. 71 (2): 298–301. PMID 6266250. Unknown parameter |month= ignored (help)
↑ Ardalan M, Shoja MM (2009). "Cytomegalovirus-induced adrenal insufficiency in a renal transplant recipient". Transplant. Proc. 41 (7): 2915–6. doi:10.1016/j.transproceed.2009.07.024. PMID 19765472. Unknown parameter |month= ignored (help)
↑ Mihalache A, Lamy O, Waeber G, Schneider A (2007). "[Adrenal insufficiency and hypercalcemia--an unusual presentation]". Praxis (Bern 1994) (in German). 96 (45): 1761–5. PMID 18050601. Unknown parameter |month= ignored (help)
↑ Kawamura M, Miyazaki S, Mashiko S; et al. (1998). "Disseminated cryptococcosis associated with adrenal masses and insufficiency". Am. J. Med. Sci. 316 (1): 60–4. PMID 9671046. Unknown parameter |month= ignored (help)
↑ Turan S, Hughes C, Atay Z; et al. (2012). "An atypical case of familial glucocorticoid deficiency without pigmentation caused by coexistent homozygous mutations in MC2R (T152K) and MC1R (R160W)". J. Clin. Endocrinol. Metab. 97 (5): E771–4. doi:10.1210/jc.2011-2414. PMC 3396854. PMID 22337906. Unknown parameter |month= ignored (help)
↑ Francke U, Harper JF, Darras BT; et al. (1987). "Congenital adrenal hypoplasia, myopathy, and glycerol kinase deficiency: molecular genetic evidence for deletions". Am. J. Hum. Genet. 40 (3): 212–27. PMC 1684111. PMID 2883886. Unknown parameter |month= ignored (help)
↑ Pedersen-Bjergaard U, Thorsteinsson B, Kirkegaard BC (1996). "[Pituitary function in hemochromatosis]". Ugeskr. Laeg. (in Danish). 158 (13): 1818–22. PMID 8650756. Unknown parameter |month= ignored (help)
↑ Pedreira CC, Savarirayan R, Zacharin MR (2004). "IMAGe syndrome: a complex disorder affecting growth, adrenal and gonadal function, and skeletal development". J. Pediatr. 144 (2): 274–7. doi:10.1016/j.jpeds.2003.09.052. PMID 14760276. Unknown parameter |month= ignored (help)
↑ Weits J, Sprenger HG, Ilic P, van Klingeren B, Elema JD, Steensma JT (1991). "[Mycobacterium avium disease in AIDS patients; diagnosis and therapy]". Ned Tijdschr Geneeskd (in Dutch; Flemish). 135 (52): 2485–9. PMID 1758516. Unknown parameter |month= ignored (help)
↑ Dispenzieri A, Kyle RA, Lacy MQ; et al. (2003). "POEMS syndrome: definitions and long-term outcome". Blood. 101 (7): 2496–506. doi:10.1182/blood-2002-07-2299. PMID 12456500. Unknown parameter |month= ignored (help)
↑ Gostiljac DM, Dordević PB, Maric-zivković J, Canović F (2005). "[Sarcoidosis localized in endocrine glands]". Med. Pregl. 58 Suppl 1: 25–9. PMID 16526262.

Template:WikiDoc Sources

[pmid26307884-1] Ham PB, Cunningham AJ, Mentzer CJ, Ahmad A, Young LS, Abuzeid AM (2015). "Traumatic panhypopituitarism resulting in acute adrenal crisis". J Trauma Acute Care Surg. 79 (3): 484–9. doi:10.1097/TA.0000000000000771. PMID 26307884.

[pmid26363354-2] Puar TH, Stikkelbroeck NM, Smans LC, Zelissen PM, Hermus AR (2016). "Adrenal Crisis: Still a Deadly Event in the 21st Century". Am J Med. 129 (3): 339.e1–9. doi:10.1016/j.amjmed.2015.08.021. PMID 26363354.

[urlwww.ucdenver.edu-3] "www.ucdenver.edu" (PDF).

[pmid11196451-4] 4.0 ^4.1 Huebner A, Yoon SJ, Ozkinay F; et al. (2000). "Triple A syndrome--clinical aspects and molecular genetics". Endocr. Res. 26 (4): 751–9. PMID 11196451. Unknown parameter |month= ignored (help)

[pmid8441467-5] Mosser J, Douar AM, Sarde CO; et al. (1993). "Putative X-linked adrenoleukodystrophy gene shares unexpected homology with ABC transporters". Nature. 361 (6414): 726–30. doi:10.1038/361726a0. PMID 8441467. Unknown parameter |month= ignored (help)

[pmid22629505-6] Shashidhar PK, Shashikala GV (2012). "Low dose adrenocorticotropic hormone test and adrenal insufficiency in critically ill acquired immunodeficiency syndrome patients". Indian J Endocrinol Metab. 16 (3): 389–94. doi:10.4103/2230-8210.95680. PMC 3354846. PMID 22629505. Unknown parameter |month= ignored (help)

[pmid11217816-7] Eledrisi MS, Verghese AC (2001). "Adrenal insufficiency in HIV infection: a review and recommendations". Am. J. Med. Sci. 321 (2): 137–44. PMID 11217816. Unknown parameter |month= ignored (help)

[pmid22506635-8] Cocco C, Meloni A, Mariotti S; et al. (2012). "Novel neuronal and endocrine autoantibody targets in autoimmune polyendocrine syndrome type 1". Autoimmunity. 45 (6): 485–94. doi:10.3109/08916934.2012.680632. PMID 22506635. Unknown parameter |month= ignored (help)

[pmid6266250-9] Osa SR, Peterson RE, Roberts RB (1981). "Recovery of adrenal reserve following treatment of disseminated South American blastomycosis". Am. J. Med. 71 (2): 298–301. PMID 6266250. Unknown parameter |month= ignored (help)

[pmid19765472-10] Ardalan M, Shoja MM (2009). "Cytomegalovirus-induced adrenal insufficiency in a renal transplant recipient". Transplant. Proc. 41 (7): 2915–6. doi:10.1016/j.transproceed.2009.07.024. PMID 19765472. Unknown parameter |month= ignored (help)

[pmid18050601-11] Mihalache A, Lamy O, Waeber G, Schneider A (2007). "[Adrenal insufficiency and hypercalcemia--an unusual presentation]". Praxis (Bern 1994) (in German). 96 (45): 1761–5. PMID 18050601. Unknown parameter |month= ignored (help)

[pmid9671046-12] Kawamura M, Miyazaki S, Mashiko S; et al. (1998). "Disseminated cryptococcosis associated with adrenal masses and insufficiency". Am. J. Med. Sci. 316 (1): 60–4. PMID 9671046. Unknown parameter |month= ignored (help)

[pmid22337906-13] Turan S, Hughes C, Atay Z; et al. (2012). "An atypical case of familial glucocorticoid deficiency without pigmentation caused by coexistent homozygous mutations in MC2R (T152K) and MC1R (R160W)". J. Clin. Endocrinol. Metab. 97 (5): E771–4. doi:10.1210/jc.2011-2414. PMC 3396854. PMID 22337906. Unknown parameter |month= ignored (help)

[pmid2883886-14] Francke U, Harper JF, Darras BT; et al. (1987). "Congenital adrenal hypoplasia, myopathy, and glycerol kinase deficiency: molecular genetic evidence for deletions". Am. J. Hum. Genet. 40 (3): 212–27. PMC 1684111. PMID 2883886. Unknown parameter |month= ignored (help)

[pmid8650756-15] Pedersen-Bjergaard U, Thorsteinsson B, Kirkegaard BC (1996). "[Pituitary function in hemochromatosis]". Ugeskr. Laeg. (in Danish). 158 (13): 1818–22. PMID 8650756. Unknown parameter |month= ignored (help)

[pmid14760276-16] Pedreira CC, Savarirayan R, Zacharin MR (2004). "IMAGe syndrome: a complex disorder affecting growth, adrenal and gonadal function, and skeletal development". J. Pediatr. 144 (2): 274–7. doi:10.1016/j.jpeds.2003.09.052. PMID 14760276. Unknown parameter |month= ignored (help)

[pmid1758516-17] Weits J, Sprenger HG, Ilic P, van Klingeren B, Elema JD, Steensma JT (1991). "[Mycobacterium avium disease in AIDS patients; diagnosis and therapy]". Ned Tijdschr Geneeskd (in Dutch; Flemish). 135 (52): 2485–9. PMID 1758516. Unknown parameter |month= ignored (help)

[pmid12456500-18] Dispenzieri A, Kyle RA, Lacy MQ; et al. (2003). "POEMS syndrome: definitions and long-term outcome". Blood. 101 (7): 2496–506. doi:10.1182/blood-2002-07-2299. PMID 12456500. Unknown parameter |month= ignored (help)

[pmid16526262-19] Gostiljac DM, Dordević PB, Maric-zivković J, Canović F (2005). "[Sarcoidosis localized in endocrine glands]". Med. Pregl. 58 Suppl 1: 25–9. PMID 16526262.

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@@ Line 10: / Line 10: @@
 Life-threatening causes of secondary adrenal insufficiency include causes of acute [[adrenal crisis]]/insufficiency:
 * Acute withdrawal of [[steroids]].
-* Traumatic hypopituitarism.<ref name="pmid26307884">{{cite journal| author=Ham PB, Cunningham AJ, Mentzer CJ, Ahmad A, Young LS, Abuzeid AM| title=Traumatic panhypopituitarism resulting in acute adrenal crisis. | journal=J Trauma Acute Care Surg | year= 2015 | volume= 79 | issue= 3 | pages= 484-9 | pmid=26307884 | doi=10.1097/TA.0000000000000771 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26307884  }} </ref>
+* Traumatic [[hypopituitarism]].<ref name="pmid26307884">{{cite journal| author=Ham PB, Cunningham AJ, Mentzer CJ, Ahmad A, Young LS, Abuzeid AM| title=Traumatic panhypopituitarism resulting in acute adrenal crisis. | journal=J Trauma Acute Care Surg | year= 2015 | volume= 79 | issue= 3 | pages= 484-9 | pmid=26307884 | doi=10.1097/TA.0000000000000771 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26307884  }} </ref>
 * [[Adrenal hemorrhage]]
 ** [[Waterhouse-Friderichson syndrome]]
@@ Line 26: / Line 26: @@
 **Infections- [[tuberculosis]]
 **Pituitary infarction
-***Pituitary apoplexy
+***[[Pituitary apoplexy]]
 ***[[Sheehan's syndrome]]
 **Pituitary removal
@@ Line 34: / Line 34: @@
 Less common causes of secondary adrenal insufficiency include:
 *Pituitary causes
-**Lymphocytic hypophysitis
+**[[Hypophysitis|Lymphocytic hypophysitis]]
 **Tumors- [[craniopharyngioma]], [[metastasis]],
@@ Line 43: / Line 43: @@
 ===Causes by Organ System===
-{|style="width:80%; height:100px" border="1"
+{| style="width:80%; height:100px" border="1"
-|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
+| style="width:25%" bgcolor="LightSteelBlue" ; border="1" | '''Cardiovascular'''
-|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Arteritis]], [[Hypotension]], [[Hemorrhage]], [[Infarction]]
+| style="width:75%" bgcolor="Beige" ; border="1" | [[Arteritis]], [[Hypotension]], [[Hemorrhage]], [[Infarction]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Chemical / poisoning'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Dermatologic'''
-|bgcolor="Beige"| [[POEMS syndrome]]
+| bgcolor="Beige" | [[POEMS syndrome]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Drug Side Effect'''
-|bgcolor="Beige"| [[Aminoglutethimide]], [[Ciclesonide]], [[Cidofovir]], [[Corticosteroid]] withdrawal, [[Dexamethasone]], [[Flunisolide]], [[Pembrolizumab]],[[prednisolone]], [[Trilostane]]
+| bgcolor="Beige" | [[Aminoglutethimide]], [[Ciclesonide]], [[Cidofovir]], [[Corticosteroid]] withdrawal, [[Dexamethasone]], [[Flunisolide]], [[Pembrolizumab]],[[prednisolone]], [[Trilostane]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Ear Nose Throat'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Endocrine'''
-|bgcolor="Beige"| [[Allgrove syndrome]], [[Achalasia-addisonian syndrome]], [[Adrenal aplasia]] / [[adrenal 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="Beige" | [[Allgrove syndrome]], [[Achalasia-addisonian syndrome]], [[Adrenal aplasia]] / [[adrenal 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"
+|- bgcolor="LightSteelBlue"
 | '''Environmental'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Gastroenterologic'''
-|bgcolor="Beige"| [[Allgrove syndrome]], [[Achalasia-addisonian syndrome]], [[Hemochromatosis ]]
+| bgcolor="Beige" | [[Allgrove syndrome]], [[Achalasia-addisonian syndrome]], [[Hemochromatosis ]]
 |-
-|-bgcolor="LightSteelBlue"
+|- 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]], Combined pituitary hormone deficiency (CPHD), [[Proopiomelanocortin]] deficiency ([[POMC]]), Isolated ACTH deficiency
+| bgcolor="Beige" | [[Congenital adrenal hyperplasia]], [[Cytochrome P450 oxidoreductase deficiency]], [[Glycerol kinase deficiency]], [[Hereditary ACTH resistance]], [[IMAGE syndrome]], [[X-linked adrenal hypoplasia congenita]], Combined pituitary hormone deficiency (CPHD), [[Proopiomelanocortin]] deficiency ([[POMC]]), Isolated ACTH deficiency
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Hematologic'''
-|bgcolor="Beige"| [[Anticoagulation]], [[Coagulopathy ]], [[Embolus]], [[Leukemia]], [[Lymphoma ]], [[Thrombosis]]
+| bgcolor="Beige" | [[Anticoagulation]], [[Coagulopathy ]] , [[Embolus]], [[Leukemia]], [[Lymphoma ]] , [[Thrombosis]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Iatrogenic'''
-|bgcolor="Beige"| [[Iatrogenic]], [[Radiation therapy]], Chronic steroid therapy
+| bgcolor="Beige" | [[Iatrogenic]], [[Radiation therapy]], Chronic steroid therapy
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Infectious Disease'''
-|bgcolor="Beige"| [[AIDS]], [[Blastomycosis]], [[CMV]], [[Coccidiomycosis]], [[Cryptococcosis]], [[Histoplasmosis ]], [[Mycobacterium avium intracellulaire]] ([[MAI]]), [[Sepsis]], [[Syphilis]], [[Toxoplasmosis]], [[Tuberculosis]], [[Waterhouse-Friderichson syndrome ]]
+| bgcolor="Beige" | [[AIDS]], [[Blastomycosis]], [[CMV]], [[Coccidiomycosis]], [[Cryptococcosis]], [[Histoplasmosis ]] , [[Mycobacterium avium intracellulaire]] ([[MAI]]), [[Sepsis]], [[Syphilis]], [[Toxoplasmosis]], [[Tuberculosis]], [[Waterhouse-Friderichson syndrome ]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Musculoskeletal / Ortho'''
-|bgcolor="Beige"| [[IMAGE syndrome]]
+| bgcolor="Beige" | [[IMAGE syndrome]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Neurologic'''
-|bgcolor="Beige"| [[Adrenoleukodystrophy]], [[Coma]], [[Craniopharyngioma]], [[Panhypopituitarism]], [[POEMS syndrome]]
+| bgcolor="Beige" | [[Adrenoleukodystrophy]], [[Coma]], [[Craniopharyngioma]], [[Panhypopituitarism]], [[POEMS syndrome]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Nutritional / Metabolic'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Obstetric/Gynecologic'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Oncologic'''
-|bgcolor="Beige"| [[Craniopharyngioma]], [[Kaposi's sarcoma]], [[Leukemia]], [[Lymphoma ]], pituitary [[metastasis]]
+| bgcolor="Beige" | [[Craniopharyngioma]], [[Kaposi's sarcoma]], [[Leukemia]], [[Lymphoma ]] , pituitary [[metastasis]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Ophthalmologic'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Overdose / Toxicity'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Psychiatric'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Pulmonary'''
-|bgcolor="Beige"| [[Sarcoidosis]],
+| bgcolor="Beige" | [[Sarcoidosis]],
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Renal / Electrolyte'''
-|bgcolor="Beige"| [[Uremia]], [[Waterhouse-Friderichson syndrome ]]
+| bgcolor="Beige" | [[Uremia]], [[Waterhouse-Friderichson syndrome ]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Rheum / Immune / Allergy'''
-|bgcolor="Beige"| [[Autoimmune]], [[Autoimmune polyendocrine syndrome type 2]], [[Sarcoidosis]]
+| bgcolor="Beige" | [[Autoimmune]], [[Autoimmune polyendocrine syndrome type 2]], [[Sarcoidosis]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Sexual'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Trauma'''
-|bgcolor="Beige"| [[Trauma]]
+| bgcolor="Beige" | [[Trauma]]
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Urologic'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Dental'''
-|bgcolor="Beige"| No underlying causes
+| bgcolor="Beige" | No underlying causes
 |-
-|-bgcolor="LightSteelBlue"
+|- bgcolor="LightSteelBlue"
 | '''Miscellaneous'''
-|bgcolor="Beige"| [[Amyloidosis]], [[Idiopathic]], [[Iatrogenic]], [[Radiation therapy]], [[Surgery]], Surgical removal of [[pituitary]], Surgical removal of [[hypothalamus]]
+| bgcolor="Beige" | [[Amyloidosis]], [[Idiopathic]], [[Iatrogenic]], [[Radiation therapy]], [[Surgery]], Surgical removal of [[pituitary]], Surgical removal of [[hypothalamus]]
 |-
 |}