Sandbox:Amd

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Adrenal Insufficiency

Disease	Clinical history/findings							Causes	Investigations/ Laboratory findings				Medical management	Surgical management
	Hypotension	Skin pigmentation/ findings	Fatigue	Anorexia/ Weightloss	Abdominal pain	Muscle weakness	Other history/ findings		Hypo natremia	Cortisol levels	Gold Standard	Other
Differentiating amongst adrenal insufficiencies
Primary adrenal insufficiency/ Addison's disease	✔	✔	✔	✔	✔	✔	Nausea and Vomiting Hypoglycemia	Autoimmune/idiopathic Infections- Tuberculosis, histoplasmosis	✔	↓	Cosyntropin/ ACTH stimulation test	Hyperkalemia
Secondary adrenal insufficiency	±	–	✔	✔	–	±	Hypoglycemia (more than primary adrenal insufficiency) Signs of pituitary tumor- Headache, visual field defects (bitemporal hemianopsia)	Hypopituitarism- Tumors, infections, hemorrhage/trauma Drugs- Chronic steroid therapy and its withdrawal, Opiates Genetic- Combined pituitary hormone deficiency (CPHD), POMC (Proopiomelanocortin) gene deficiency	–	Normal	Cosyntropin/ ACTH stimulation test	CT scan/ MRI scan showing pituitary causes
Acute adrenal insufficiency/ Acute adrenal crisis	↓↓	±	✔	✔	✔	±	Signs of shock Altered mental status/ Loss of consciousness/ Coma Fever Nausea/ Vomiting	Infection Trauma Surgery Anesthesia(Etomidate)	✔	Normal to Low	Cosyntropin/ ACTH stimulation test	ECG(Electrocardiogram) CBC (Complete blood count) BUN (Blood urea nitrogen) Creatinine	I/V 0.9% saline 1-3 liters within 12-24 hours I/V Dexamethasone 4 mg bolus, or, I/V hydrocortisone 50 mg bolus
Differentiating Adrenal Insufficiency from other diseases
Adrenal hemorrhage/ Waterhouse Friderichsen syndrome	✔, orthostatic	±	✔	±	✔	–	Fever Tachycardia Dizziness Nausea/Vomiting Diarrhea	Infection Sepsis- pneumonia, Waterhouse Friderichsen syndrome-meningococcemia Cardiac- Congestive heart failure (CHF), Myocardial infarction Gastrointestinal- Acute Pancreatitis, Cirrhosis Bleeding situations- Spontaneous abortions, Thrombocytopenia, Anticoagulants use, Surgery, Heparin-induced thrombocytopenia Trauma Thrombotic phenomenon- pulmonary embolus, deep venous thrombosis, antiphospholipid antibody syndrome Tumors- Adrenal adenomas, Pheochromocytoma	✔			CBC (Complete blood count) CT scan
Syndrome of inappropriate antidiuretic hormone (SIADH)	–	–	–	–	–	–	Nausea/vomiting Cramps Depressed mood Irritability Confusion Hallucinations Seizures, stupor or coma	Head trauma-subarachnoid hemorrhage Tumors- metastasis Infections- Brain abscess Drugs- Chlorpropamide, Cyclophosphamide, Carbamazepine, Selective serotonin reuptake inhibitors, Methylenedioxymethamphetamine (MDMA, commonly called Ecstasy)	✔	Normal	Water deprivation test	Decreased osmolality Euvolemia Sodium in urine typically >20 mEq/	Mild- Fluid restriction Moderate- Loop diuretics Severe Hypertonic (3%) saline
Salt-depletion nephritis	✔	–	–	–	✔ Flank pain	–	Fever Dysuria Pyuria Oliguria		✔	↑		<15:1 BUN:CR