A 34-year old woman presented with fatigue, weight loss, and depression for 12 months. Tests confirmed she had Addison's disease, which is caused by insufficient production of cortisol and other steroid hormones by the adrenal cortex. Addison's disease can be caused by autoimmune destruction of the adrenal cortex, tuberculosis, fungal or other infections, cancer, surgery, or genetic defects. Patients require lifelong hydrocortisone replacement therapy and monitoring during periods of stress.

1. (Addison’s Disease)

2. Case Scenario
• A 34 year old woman presented with
a 12 month history of increasing
tiredness, anorexia, weight loss, and
depression. During that period, she
had tried two different
antidepressant tablets without
benefit. A short Synacthen
(tetracosactide) test showed an
inadequate serum cortisol response,
which together with raised plasma
adrenocorticotrophic hormone
confirmed the diagnosis of Addison’s
disease.

3. What is Addison’s disease?
• Addison's disease is hypo function of the adrenal
cortex.
• Endocrine disorder also known as Adrenocortical
Insufficiency.
• There is a decrease in adrenal steroids which are:
glucocorticoids, mineral corticoids, and androgen.
• The adrenal cortex function is inadequate to
meet the patients need for cortical steroids.
• Addison’s disease occurs when 90% of the
adrenal cortex has been destroyed

4. TYPES
• There are three major types of adrenal insufficiency.
 Primary adrenal insufficiency:
is due to impairment of the
adrenal glands.(Addison’s Disease)
 Secondary adrenal insufficiency:
is caused by impairment of the
pituitary gland or hypothalamus.
 Tertiary adrenal insufficiency:
is due to hypothalamic disease
and decrease in corticotropin releasing factor
(CRF).

5. Signs and Symptoms
1. Fatigue and weakness.
2. Anorexia.
3. Nausea.
4. Vomiting.
5. Weight loss.
6. Abdominal pain.
7. Diarrhoea.

6. 8. Constipation.
9. Syncope.
10. Dizziness.
11. Confusion.
12. Personality change.
13. Irritability.
14. Darkening of the skin
15. Skin rash or lesions

7. Causes
There are 3 main causes of adrenal insufficiency:
• Autoimmune Disorders:
The gradual destruction of the adrenal
cortex, the outer layer of the adrenal glands, by the
body's immune system causes up to 80 percent of
Addison's disease cases. Adrenal insufficiency occurs
when at least 90 percent of the adrenal cortex has
been destroyed. As a result, often both cortisol and
aldosterone are lacking
• Tuberculosis:
Tuberculosis (TB), an infection
that can destroy the adrenal glands,
accounts for less than 20 percent of cases
of Addison's disease in developed countries.

8. Other Causes
Less common causes of Addison's disease are:
• chronic infection, mainly fungal infections
• cancer cells spreading from other parts of the
body to the adrenal glands
• amyloidosis, a disease that causes abnormal
protein buildup in, and damage to, various
organs
• surgical removal of the adrenal glands
• AIDS-associated infections
• bleeding into the adrenal glands
• genetic defects including abnormal adrenal
gland development, an inability of the adrenal
gland to respond to ACTH, or a defect in adrenal
hormone production

10. Diagnostic Tests
Early stages difficult to diagnose.
• Check Cortisol levels
• ACTH Stimulation Test
• CRH Stimulation Test
• X-RAY
• Fasting blood sugar
• Serum potassium
• Serum sodium

11. Case No. 1
• A 23-year-old female presented to
the Emergency Department
complaining of nausea and vomiting
for one week. She also reported 8
months of progressively worsening
fatigue. The patient was previously
very active as a ballet student, but
for the past 8 months she stopped
participating in ballet because of
lack of energy. She was now living
with her mother and sleeping or
watching television most of the day.
She repeatedly denied purposefully
restricting food intake or binging and
purging behaviors. There was no
abdominal pain, diarrhea, fevers,
dysuria or headache.

12. •Diagnosis:
The patient was diagnosed
with primary adrenal insufficiency
(Addison's disease) along with
autoimmune hypothyroidism
consistent with autoimmune
polyendocrine syndrome type II. The
severe hypovolemic hyponatremia
was thought due to adrenal
insufficiency.

13. Case No. 2
• A 24-year-old woman was acutely
unwell with a background of several
months of generalised fatigue and
intermittent headaches. She had
unremarkable neurological and
systemic examination with a normal
computerised tomography and
magnetic resonance imaging of the
brain. Normal cerebrospinal fluid but
increased opening pressure at lumbar
puncture suggested intracranial
hypertension. A flat short synacthen
test and raised level of
adrenocorticotrophic hormone were
consistent with primary adrenal failure.

14. •Diagnosis:
Addison's disease is due to primary
adrenal failure. It is an uncommon
condition with equal prevalence in both
males and females. The onset of
symptoms is gradual and manifestation
is non specific, hence diagnosis is easily
missed without a high index of suspicion.

15. Treatment
• Hydrocortisone Replacement Therapy:
In adrenal crisis, patients need an
immediate injection of hydrocortisone
through a vein (intravenous) or muscle
(intramuscular). You may receive intravenous
fluids if you have low blood pressure.

16. Surgery
• Patients with chronic adrenal
insufficiency who need surgery
with general anesthesia are
treated with injections of
hydrocortisone and saline.
Injections begin on the evening
before surgery and continue until
the patient is fully awake and able
to take medication by mouth. The
dosage is adjusted until the
maintenance dosage given before
surgery is reached.

17. Physical Therapy Management
(current best evidence)
There are some key points for the physical
therapy management of patients with
Addison's disease:
• Since these patients have a decreased
response to stress, physical stress should be
minimized as much as possible during
activity and the treatment program should
be "very gradually progressed" as the
individual feels comfortable
• Aquatics therapy should NOT be utilized
with these patients because the heat and
humidity of the pool will place increased
demands of cortisol on their bodies to
increase their blood pressure

18. • Vital signs should be constantly
monitored, especially when initiating
or progressing an exercise program
• Monitor for the signs of an impending
addisonian crisis, which includes
"dizziness, nausea, profuse sweating,
elevated heart rate, and tremors or
shaking"
• Patients should be referred back to
the physician if there is a suspected
infection, since an infection places
extra stress on the patient