Adrenal Insufficiency


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Adrenal Insufficiency

  1. 1. بسم الله الرحمن الرحيم <br />RIBAT UNIVERSITY HOSPITAL <br />DEPARTMENT OF MEDICINE<br />Unite (E)<br />Adrenal Insufficiency<br />Dr. EyadGadour<br />(MBBS National Ribat University)<br />
  2. 2. Basics Description<br />- Inadequate hydrocortisone secretion to meet body&apos;s stress requirement<br />- Adrenal deficiency:<br />1- Inadequate cortisol<br />2- Unresponsive to stimulation with adrenocorticotropic hormone (ACTH)<br />- Functional hypoadrenalism:<br />1- Inadequate cortisol<br />2- Partial responsive to stimulation with ACTH<br />- Addisonian crisis (acute adrenal insufficiency):<br />1- Life-threatening emergency<br />2- Precipitated by intensification of:<br />* Chronic adrenal insufficiency<br />* Acute adrenal hemorrhage<br />* Rapid steroid withdrawal<br />* Treatment of hypothyroidism with unrecognized adrenal disease<br />* Steroid-dependent patient under stress owing to pregnancy, surgery, trauma, infection, or dehydration<br />
  3. 3. EtiologyPrimary Adrenal Failure<br />1- Adrenal dysgenesis/impaired steroidogene:<br />Congenital hypoplasia<br />Allgrove syndrome:<br />ACTH resistance<br />Achalasia<br />Alacrima<br />Glycerol kinase deficiency:<br />Psychomotor retardation<br />Hypogonadism<br />Muscular dystrophy<br />Congenital hyperplasia<br />Aldosteronesynthetase deficiency<br />Mitochondrial disease<br />
  4. 4. 2- Adrenal destruction:<br />- Autoimmune:<br />1- Autoimmune polyglandular syndrome types 1 and 2 (alopecia universalis, chronic mucocutaneouscandidiasis, hypoparathyroid, thyroid autoimmunity, diabetes, celiac disease, pernicious anemia)<br />2- Adrenoleukodystrophy<br />- Infectious:<br />1- Granulomatous: tuberculosis<br />2- Protozoal and fungal: histoplasmosis, coccidioidomycosis, candidiasis<br />3- Viral: cytomegalovirus, herpes simplex virus, and HIV<br />4- Bacterial<br />- Infiltration:<br />1- Sarcoid<br />2- Neoplasm<br />3- Hemochromatosis<br />4- Amyloidosis<br />5- Iron depletion<br />
  5. 5. 3- Postadrenalectomy<br />4- Hemorrhage:<br />1- Sepsis: particularly meningococcemia, Pseudomonas infection<br />2- Birth trauma/anoxia<br />3- Pregnancy<br />4- Seizures<br />5- Anticoagulants<br />6- Rhabdomyolysis<br />5- Pharmacologic inhibition:<br />Etomidate((Amidate), a nonbarbiturate, is used for induction of anesthesia).<br />Herbal medications(الاعشاب)<br />Ketoconazole ( gluoccorticoid antagonist )<br />Metyrapone<br />Suramin<br />
  6. 6. Secondary Adrenal Failure<br />Pituitary insufficiency:<br />- Sepsis<br />- Head trauma<br />- Hemorrhage<br />- Infarction (Sheehan syndrome)<br />- Infiltration: neoplasm, amyloid, sarcoid, hemochromatosis<br />- Adrenocorticotropic hormone deficiency<br />- Pharmacologic: glucocorticoid administration, herbal medications<br />Tertiary Adrenal Failure<br />- Hypothalamus insufficiency<br />- Sepsis<br />- Infiltrative: neoplasm, amyloid, sarcoid, hemochromatosis<br />- Head trauma<br />
  7. 7. Diagnosis<br />Signs and Symptoms<br />Symptoms:<br />Depression<br />Lethargy<br />Malaise<br />Myalgias<br />Anorexia<br />Abdominal pain<br />Nausea<br />Vomiting<br />Dehydration (found in primary adrenal insufficiency only)<br />Salt craving<br />Signs:<br />Fever or hypothermia<br />Mental status changes<br />Tachycardia<br />Orthostatic blood pressure changes or frank shock<br />Weight loss<br />Goiter<br />Hypogonadism<br />Hyperkalemia<br />Sodium depletion<br />Eosinophilia<br />Hyperpigmentation (found in primary adrenal insufficiency only)<br />Vitiligo<br />Addisonian crisis:<br />Hypotension and shock<br />Hyponatremia<br />Hyperkalemia<br />Hypoglycemia<br />
  8. 8. Essential Workup<br />Laboratory confirmation of diagnosis not possible in emergency department<br />Adrenal crisis: life-threatening condition:<br />High degree of suspicion should prompt initiation of therapy before definitive diagnosis.<br />Plasma cortisollevel &lt;20 آµg/dL accompanied by shock suggests adrenal insufficiency.<br />Electrolytes:<br />Potassium<br />Sodium<br />BUN, creatinine:<br />Elevated owing to dehydration<br />Serum glucose levels may be low<br />
  9. 9. Tests<br />Lab<br />CBC with differential:<br />Anemia<br />Eosinophilia<br />Lymphocytosis<br />Arterial blood gases:<br />Hypoxemia<br />Acidosis<br />Cosyntropin stimulation test:<br />Adrenal deficiency:<br />Random serum cortisol &lt;20 آµg/dL (while stressed)<br />ACTH stimulation unresponsive<br />Functional hypoadrenalism:<br />Random serum cortisol = 20 آµg/dL (while stressed)<br />Sixty minutes post ACTH stimulation &lt;30 آµg/dL or delta cortisol (60 minutes - baseline) = 9 آµg/dL<br />Search for underlying infection.<br />Imaging<br />ECG<br />Chest radiograph<br />
  10. 10. Differential Diagnosis<br />Sepsis<br />Shock from any cause<br />Acute abdominal emergency<br />
  11. 11. Treatment<br />Initial Stabilization<br />Airway, breathing, and circulation management (ABCs)<br />Cardiac monitor<br />Blood pressure support for hypotension:<br />Normal saline (0.9%) IV fluids 500 mL–1 L (peds: 20 mL/kg) bolus<br />Avoid pressors (if possible):<br />May precipitate dysrhythmias<br />Supplemental oxygen to meet metabolic needs<br />Correct hyperthermia:<br />Initiate cooling measures.<br />ED Treatment<br />Glucocorticoid replacement:<br />Hydrocortisone: 100 mg or Dexamethasone: 4 mg <br />Dexamethasone will not interfere with results of cosyntropin stimulation tests.<br />Volume expansion:<br />D5W 0.9% normal saline at rate of 500–1,000 mL/h for first 3–4 hours<br />Care should be taken to note patient&apos;s age, volume, and cardiac and renal function.<br />For hypoglycemia:<br />D50W<br />Treat life-threatening dysrhythmias secondary to hyperkalemia with calcium ,Sodium bicarbonate: 1–2 mEq/kg IV, and Insulin (regular): 10 units by IV push<br />/glucose.<br />Identification and correction of underlying precipitant<br />
  12. 12. Follow-Up Disposition<br />Admission Criteria<br />All patients with acute adrenal insufficiency<br />ICU admission for patients with unstable or potentially unstable cases<br />Discharge Criteria<br />Normal laboratory evaluation with treated adrenal insufficiency<br />
  13. 13. Thank you<br />