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adrenal glands (Adrenal insufficiency (AI) (Diagnosis * (Laboratory…

- - - - Iatrogenic - surgical removal, drugs aminoglutethimide, ketoconasole, mitotane
        
        Congenital – CAH, adrenal unresponsiveness to ACTH
        
        Isolated mineralocorticoid deficiency ACE inhibitors, heparine therapy
        
        Autoimmune disease – 90% (antigen:21-hydroxylase) = Addison’s disease
        
        Tuberculosis ( most common) or other rare infections (CMV, fungal, HIV)
        
        Vascular – adrenal hemorrhage, sepsis (Meningoccocus, Pseudomonas), thrombosis
        
        Infiltration – metastatic ca (commonly sclc), lymphoma, sarcoidosis, hemochromatosis, amyloidosis
    - - Depends on the loss of adrenal mass and whether mineralocorticoid production is preserved
        
        onset is often gradual and may go undetected
        
        illness or other stress (accident, operation) precipitates an adrenal crisis
      - CHRONIC PRIMARY AI:
        common: weakness, fatigue, anorexia
        Gastrointestinal: nausea, vomiting, abdominal pain, diarrhoea or constipation
        Orthostatic hypotension – syncope from postural hypotension
        Arthralgia, myalgia
        Psychiatric: mild memory impairment, psychosis or depression
        Weight loss
        Hyperpigmentation – generalized or localized to regions of repeated trauma (elbow, knees, buccal mucosa), palmar creases and new scars
        Vitiligo (in autoimmune adrenalitis)
        Loss of axillary and pubic hair – more in woman
        Auricular cartilage calcification
      - Adrenal crisis (Addisonian crisis, acute adrenal insufficiency)
        
        May complicate the course of chronic disease
        May be precipitated by a serious infection, bilateral adrenal infarction or hemorrhage
        It is rare in patients with secondary/tertiary adrenal insufficiency
        The main manifestation is SHOCK
        Major factor precipitating an adrenal crisis is mineralocorticoid defficiency
        The main clinical problem is hypotension
        Can occur in patients receiving appriopriate doses of glucocorticoids if their mineralocorticoid requirements are not met
        Patients with secondary adrenal insufficiency and normal aldosterone secretion rarely present adrenal crisis
        
        Nonspecific: anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, confusion or coma
        Dehydratation, hyperkalemia, hyponatremia
        Hypoglycemia is rare in acute adrenal insufficiency and more common in secondary adrenal insufficiency (due to GH deficciency)
        Symptoms and signs relating to the primary cause of adrenal insufficiency
  - - - Similar to those of primary
        
        Hyperpigmentation is not present = „white Addison”
        
        Dehydratation, hyperkalemia are not present (preserved production of mineralocorticoids)
        
        Hyponatremia and increased intravascular volume are due to increased vasopressin secretion
        
        Hypoglycemia is common
  - - - Autonomic neuropathy
        
        Diabetic nephropathy
        
        Tubulointerstitial diseases
        
        Drugs: NSAID, ACEI, β-adrenergic antagonists
  - - - a life threatening emergency - requires immediate treatment:
        - i.v. administration of hydrocortisone100/d
        
        i.v. administaration of large volumes of normal
        saline solutions
        
        Convertion to an oral glucocorticoid maitenance dose (after 3-4 days)
        
        Fludrocortisone (mineralocorticoid) is unnecessary acutely in secondary and 3rd
    - - Life–long replacement therapy with both gluco- and mineralocorticoids
        
        Do not overtreat with gluco- and undertreat with mineralocorticoids
        
        The natural glucocorticoid – hydrocortisone (10- 15 mg per meter square body surface area) - 25- 30 mg daily given in 2-3 doses
        
        increase the dose of glucocorticoids during stress up to 3-10 times for 3 days
        
        Parenteral HC administration when the ingestion of pills is impossible
        
        High doses of HC i.v. 150-300 mg during surgery or major illness
        
        Mineralocorticoid relpacement therapy – fludrocortisone 0,1 mg daily, rarely required in secondary adrenal insufficiency
        
        Androgen replacement – is beeing increasingly considered (DHEA)