> [!key points] > - always consider adrenal crisis in presence of fluid resistant hypotension; ==orthostatic hypotension== very common finding > - [[hyponatremia]], [[hyperkalemia]], acidosis ([[Blood gas#NAGMA]]), AKI due to aldosterone deficiency > - [[hypoglycaemia|hypoglycemia]] due to cortisol deficiency > - [[hypercalcaemia|hypercalcemia]] due to redued GFR and increased proximal tubular reabsorption of calcium + bone resorption # pathophysiology inadequate cortisone and aldosterone # Causes ## Primary adrenal insufficiency - **Addison's disease** - autoimmune - most common cause - 50% of pts have other autoimmune disease - thyroid disease - hypoparathyroidism - [[Diabetes type 1|Type 1 DM]] - congenital adrenal hyperplasia - infection - most common cause in developing countries - [[Tuberculosis|TB]] - protozoal - viral - CMV, HSV, [[HIV]] - bilateral adrenal haemorrhage - anticoagulants - newborn - severe [[Sepsis]] (*Freidrich-Waterhouse syndrome*) or waterhouse-friedrich eg from meningococcal - (Don’t confuse with [sheehan syndrome](https://en.m.wikipedia.org/wiki/Sheehan's_syndrome) from pregnancy) - malignancy - primary adrenal - rare secondary (eg lung, lymphoma) - sarcoidosis - iron deposition Allgrove syndrome - autosomal recessive - adrenal insufficiency due to ACTH resistence - a/w oesophagela achalasia , neuro involvement, seen in children ## Secondary adrenal insufficiency Due to failure of **ACTH from pituitary gland** - drugs - steroids → depress adrenopituatary axis - ketoconazole - [[Checkpoint inhibitors|immune checkpoint inhibitors]] - usually patients with melanoma - sometimes irreversible - pituitary failure - hypothalamic # Assessment - fluid resistant hypotension - ==orthostatic hypotension== almost always present - anorexia, nausea, vomiting - abdo pain - lethargy - fever, myalgia - not always due to infection; sometimes loss of suppressive effects on cytokines - postural syncope - gastro symptoms improve with NaCl # Findings - hypotension BP <100 with postural drop - fatigue - weakness - [[hyponatremia]] - [[hyperkalemia]] - mild [[hypercalcaemia]] - [[hypoglycaemia|hypoglycemia]] - [[Blood gas#NAGMA]] - neutropenia # diagnosis formal diagnosis is cortisol and ACTH levels primary adrenal insufficency confirmed with positive synacthen test, ↑ ACTH levels. can have ↑ plasma renin # Treatment - NaCl fluid replacement -- may be many litres depleted - steroids: - **dexamethasone** 10mg stat then 4mg Q6H if dx suspected but not confirmed *so you can test cortisol quant* - [[hydrocortisone|hydrocort]] 250mg stat then 100mg Q6h if patient has known adrenal failure - may need fludrocortisone 100mcg - tx hypoglycaemia with 50mL 50% dextrose - other metabolic abnormalities usually corrected with rehydration and mineralocorticoid replacement - tx hyperkalemia -- generally better to give sodium bicarb because these patients are very sensitive to glucose and insulin . generally corrects with fluid, so generally tx if K >7, may need calcium gluconate as well - consider vasopressors if steroids given and still fluid-resistant # prevention - stress dose steroids at home, eg 3x daily glucocorticoid dose for 1-2 days until symptoms improvei # tags #hypoglycaemia