Secondary adrenal insufficiency laboratory findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Laboratory Findings

ACTH Stimulation Test

If the person is in adrenal crisis, the ACTH stimulation test 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. 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.

Source of pathology	CRH	ACTH	DHEA	DHEA-S	cortisol	aldosterone	renin	Na	K	Causes5
hypothalamus (tertiary)1	low	low	low	low	low3	low	low	low	low	tumor of the hypothalamus (adenoma), antibodies, environment (i.e. toxins), head injury
pituitary (secondary)	high2	low	low	low	low3	low	low	low	low	tumor of the pituitary (adenoma), antibodies, environment, head injury, surgical removal6, Sheehan's syndrome
adrenal glands (primary)7	high	high	high	high	low4	low	high	low	high	tumor of the adrenal (adenoma), stress, antibodies, environment, Addison's Disease, trauma, surgical removal (resection), miliary tuberculosis of the adrenal

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 eosinophils or lymphocytes, two types of white blood cells). Normocytic anemia may be present.
• Serum ACTH levels - elevated in primary adrenal insufficiency and decreased in secondary form.
• 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.