Adrenal Insufficiency Signs and Symptoms

Definition

  • Adrenal insufficiency (AI) is the inability of the adrenal gland to produce sufficient adrenocortical steroid hormones

Etiology

  • Rapid withdrawal of steroids in patients with adrenal atrophy due to chronic steroid therapy
    • Most common cause of acute adrenal insufficiency (AI)
  • Rapid intensification of chronic primary adrenal insufficiency caused by sepsis or acute major stress
  • May occur in patients receiving glucocorticoids if mineralocorticoid requirements are not met
  • Rare in patients with secondary or tertiary adrenal insufficiency
  • Destruction of both adrenal glands caused by acute hemorrhage
    • In children, may be caused by septicemia
    • In adults, may be caused by anticoagulant therapy or a coagulation disorder
  • Patients with congenital adrenal hyperplasia who are given drugs that inhibit steroid synthesis or increase steroid metabolism

Primary Adrenal Insufficiency (AI)

  • Progressive destruction of the adrenals which is most commonly caused by idiopathic atrophy (probably autoimmune in nature), tuberculosis (TB), fungal infections, adrenal hemorrhage, acquired immune deficiency syndrome (AIDS), etc
  • May also be caused by insufficient hormone production caused by congenital adrenal hyperplasia, enzyme inhibitors (eg Metyrapone), or cytotoxic agents (eg Mitotane), adrenal surgery

Secondary and Tertiary Adrenal Insufficiency (AI)

  • Pituitary or hypothalamic disorders
  • Suppression of the hypothalamic-pituitary axis by exogenous steroid (ie long-term glucocorticoid therapy) or endogenous steroid (eg tumor)
    • Exogenous glucocorticoid doses of 5 mg or higher Prednisolone or equivalent for >4 weeks either inhaled, injected, oral or topical, is the most common cause of drug-induced adrenal insufficiency

Signs and Symptoms

  • Usually nonspecific with insidious onset 

Primary Adrenal Insufficiency (AI):

  • Hyperpigmentation - most characteristic
  • Hyperkalemia, hyponatremia
  • Autoimmune thyroid disease
  • Vitiligo

Secondary and Tertiary Adrenal Insufficiency (AI):

  • Manifestations usually begin in the first 48 hours after steroid medication has been discontinued 
  • Similar to primary AI except that hyperpigmentation and dehydration are absent; gastrointestinal (GI) symptoms and hypotension are less prominent
  • Hyponatremia and volume expansion may be present
  • Hypoglycemia is more commonly seen than in primary AI
  • Pale skin without significant anemia
  • Prepubertal growth deficiency, delayed puberty
  • May present with clinical manifestations of pituitary or hypothalamic tumor, eg diabetes insipidus (DI)
  • Secondary hypothyroidism
  • Decreased libido and potency, amenorrhea
  • Visual symptoms, headache

Primary, Secondary and Tertiary Adrenal Insufficiency (AI):

  • Fatigue
  • Weakness
  • Salt craving
  • Orthostatic hypotension, dizziness, hypovolemic shock
  • Nausea and vomiting (N/V); abdominal pain, tenderness and guarding
  • Fever
  • Diarrhea
  • Anorexia, weight loss
  • Confusion, somnolence
  • In severe cases, delirium or coma

Signs & Symptoms of Acute Adrenal Insufficiency (AI)

  • Acute adrenal insufficiency (AI) or adrenal crisis usually occurs with concomitant injury or illness and is difficult to diagnose

Signs and symptoms may be non-specific 

  • Shock or unexplained catecholamine-resistant hypotension is the most predominant manifestation
  • Fatigue
  • Diarrhea
  • Weakness
  • Lethargy
  • Fever
  • Confusion
  • Coma
  • Anorexia
  • Nausea and vomiting
  • Metabolic acidosis
  • Abdominal pain
Patient with underlying chronic adrenal insufficiency (AI) who presents in crisis may show common symptoms of adrenal insufficiency (AI)
  • Hyperpigmentation
  • Vitiligo
  • Sparse pubic and axillary hair
  • Hyponatremia or hyperkalemia