Adrenal Insufficiency - Diagnosis and Management Summary
Primary Adrenal Insufficiency:
Most Common Cause in the US: Autoimmune Adrenalitis
Other causes: TB, fungal infection, HIV, adrenoleukodystrophy, check point inhibitors, bilateral hemorrhage or metastatic disease (rare), and drugs (ketoconazole, etomidate)
Symptoms and Exam Findings:
Fatigue (85-100%), weight loss (65-75%) w/ anorexia, abdominal pain w/ N/V (60-90%), Muscle/joint pain (10-40%), hyperpigmentation (95%), orthostatic or frank hypotension
In secondary AI, hyponatremia may still be present due to increased ADH. Hyperkalemia is absent because aldosterone levels are unaffected. Hyperpigmentation is absent (low ACTH).
Causes of Secondary Adrenal Insufficiency: Long-term steroid use (most common), pan-hypopituitarism including: pituitary tumor, TB and histoplasmosis, infiltrative diseases, check point inhibitors, lymphocytic hypophysitis, Sheehan's syndrome.
1. A STIM test can be performed at any time of the day.
2. A baseline 8am cortisol <3 is diagnostic of AI and a cortisol level of at least 18 excludes AI.
ACTH STIM TEST:
1. Obtain baseline cortisol and ACTH
2. Give 250 mcg of cosyntropin
3. Measure cortisol at 30 and 60 minutes
Cortisol level of less than 18 is diagnostic of AI
- Dr. Ann Marie Kumfer @AnnKumfer
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