Addison's disease differential diagnosis: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Addison%27s_disease]] | |||
{{CMG}} ; {{AE}} {{ADG}} | {{CMG}} ; {{AE}} {{ADG}} | ||
==Overview== | ==Overview== | ||
Addison's disease must be differentiated from other diseases that cause hypotension, skin pigmentation, and abdominal pain such as myopathies, celiac disease, Peutz-Jeghers syndrome ,anorexia nervosa, syndrome of inappropriate | Addison's disease must be differentiated from other diseases that cause [[hypotension]], [[skin pigmentation]], and [[abdominal pain]] such as [[myopathies]], [[celiac disease]], [[Peutz-Jeghers syndrome]], [[anorexia nervosa]], [[syndrome of inappropriate antidiuretic hormone]] ([[SIADH]]), [[neurofibromatosis]], [[porphyria cutanea tarda]], salt-depletion [[nephritis]] and [[bronchogenic carcinoma]]. | ||
==Differentiating Addison's disease from other Diseases== | ==Differentiating Addison's disease from other Diseases== | ||
Addison's disease (primary adrenal insufficiency) must be first differentiated from secondary and tertiary adrenal insufficiency as all the three of them present with similar symptoms due to cortisol and mineralocorticoid hormone deficiencies. | Addison's disease (primary adrenal insufficiency) must be first differentiated from secondary and tertiary adrenal insufficiency as all the three of them present with similar symptoms due to [[cortisol]] and [[mineralocorticoid]] hormone deficiencies. | ||
*Serum ACTH level can help distinguish primary from secondary/tertiary adrenal insufficiency | *Serum ACTH level can help distinguish primary from secondary/tertiary adrenal insufficiency | ||
{| | {| | ||
|- style="background: #4479BA; color: #FFFFFF; text-align: center;" | |||
!Type of | !Type of | ||
Adrenal insufficiency | Adrenal insufficiency | ||
Line 15: | Line 16: | ||
!ACTH | !ACTH | ||
!Normal ACTH | !Normal ACTH | ||
|- | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|Addison disease | |Addison disease | ||
| + | | + | ||
|>60 ng/mL | |>60 ng/mL | ||
| rowspan="2" |5-30 ng/mL | | rowspan="2" |5-30 ng/mL | ||
|- | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|Secondary / | |Secondary / | ||
tertiary adrenal insufficiency | tertiary adrenal insufficiency | ||
Line 26: | Line 27: | ||
|<5 ng/mL | |<5 ng/mL | ||
|} | |} | ||
Addison's disease must be differentiated from other diseases that cause | Addison's disease must be differentiated from other diseases that cause [[hypotension]], [[skin pigmentation]], [[muscle weakness]] and [[abdominal pain]] which include [[myopathies]], [[celiac disease]], [[Peutz-Jeghers syndrome]], [[anorexia nervosa]], [[syndrome of inappropriate antidiuretic hormone]] ([[SIADH]]), [[neurofibromatosis]], [[porphyria cutanea tarda]], salt-depletion [[nephritis]] and [[bronchogenic carcinoma]].<ref name="pmid16483775">{{cite journal |vauthors=Selva-O'Callaghan A, Labrador-Horrillo M, Gallardo E, Herruzo A, Grau-Junyent JM, Vilardell-Tarres M |title=Muscle inflammation, autoimmune Addison's disease and sarcoidosis in a patient with dysferlin deficiency |journal=Neuromuscul. Disord. |volume=16 |issue=3 |pages=208–9 |year=2006 |pmid=16483775 |doi=10.1016/j.nmd.2006.01.005 |url=}}</ref><ref name="pmid11427410">{{cite journal |vauthors=Kumar V, Rajadhyaksha M, Wortsman J |title=Celiac disease-associated autoimmune endocrinopathies |journal=Clin. Diagn. Lab. Immunol. |volume=8 |issue=4 |pages=678–85 |year=2001 |pmid=11427410 |pmc=96126 |doi=10.1128/CDLI.8.4.678-685.2001 |url=}}</ref><ref name="pmid9496878">{{cite journal |vauthors=Adams R, Hinkebein MK, McQuillen M, Sutherland S, El Asyouty S, Lippmann S |title=Prompt differentiation of Addison's disease from anorexia nervosa during weight loss and vomiting |journal=South. Med. J. |volume=91 |issue=2 |pages=208–11 |year=1998 |pmid=9496878 |doi= |url=}}</ref><ref name="pmid6414566">{{cite journal |vauthors=Lever EG, Stansfeld SA |title=Addison's disease, psychosis, and the syndrome of inappropriate secretion of antidiuretic hormone |journal=Br J Psychiatry |volume=143 |issue= |pages=406–10 |year=1983 |pmid=6414566 |doi= |url=}}</ref><ref name="pmid13356214">{{cite journal |vauthors=BELL R, PATTEE CJ |title=Addison's disease associated with neurofibromatosis |journal=Can Med Assoc J |volume=75 |issue=5 |pages=415–7 |year=1956 |pmid=13356214 |pmc=1823303 |doi= |url=}}</ref> | ||
{| | {| | ||
|-style="background: #4479BA; color: #FFFFFF; text-align: center;" | |- style="background: #4479BA; color: #FFFFFF; text-align: center;" | ||
! rowspan="2" |Disease | ! rowspan="2" |Disease | ||
! colspan="7" |Differentiating symptoms | ! colspan="7" |Differentiating symptoms | ||
! colspan="3" |Differentiating laboratory findings | ! colspan="3" |Differentiating laboratory findings | ||
! rowspan="2" |Gold standard test | ! rowspan="2" |Gold standard test | ||
|-style="background: #4479BA; color: #FFFFFF; text-align: center;" | |- style="background: #4479BA; color: #FFFFFF; text-align: center;" | ||
|'''Hypotension''' | |'''Hypotension''' | ||
|'''Abdominal pain''' | |'''Abdominal pain''' | ||
Line 45: | Line 45: | ||
|'''Other symptoms''' | |'''Other symptoms''' | ||
|'''Hyponatremia''' | |'''Hyponatremia''' | ||
| | | ' Cortisol level |Cortisol levels | ||
|'''Other labs''' | |'''Other labs''' | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|Addison's disease | |Addison's disease | ||
| + | | + | ||
Line 56: | Line 56: | ||
| + | | + | ||
| | | | ||
| | | + | ||
|Low | |Low | ||
| | | | ||
|[[ACTH stimulation test]] | |[[ACTH stimulation test]] | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|[[Myopathies]] | |[[Myopathies]] | ||
([[polymyositis]], | ([[polymyositis]], | ||
Line 78: | Line 78: | ||
| - | | - | ||
|[[Muscle biopsy]] | |[[Muscle biopsy]] | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|[[Celiac disease]] | |[[Celiac disease]] | ||
| - | | - | ||
Line 93: | Line 93: | ||
| - | | - | ||
|Abnormal [[small bowel]] [[biopsy]] | |Abnormal [[small bowel]] [[biopsy]] | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|[[Syndrome of inappropriate antidiuretic hormone|Syndrome of inappropriate anti-diuretic hormone]] | |[[Syndrome of inappropriate antidiuretic hormone|Syndrome of inappropriate anti-diuretic hormone]] | ||
[[Syndrome of inappropriate antidiuretic hormone|(SIADH)]] | [[Syndrome of inappropriate antidiuretic hormone|(SIADH)]] | ||
Line 110: | Line 110: | ||
* [[Sodium]] in [[urine]] typically >20 mEq/L | * [[Sodium]] in [[urine]] typically >20 mEq/L | ||
|Water deprivation test | |Water deprivation test | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|[[Neurofibromatosis]] | |[[Neurofibromatosis]] | ||
| - | | - | ||
Line 125: | Line 125: | ||
| - | | - | ||
|[[Skin biopsy|Biopsy of skin tissue]] | |[[Skin biopsy|Biopsy of skin tissue]] | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|[[Peutz-Jeghers syndrome]] | |[[Peutz-Jeghers syndrome]] | ||
| | | | ||
Line 139: | Line 139: | ||
| | | | ||
|Colonic [[imaging]] showing the [[Small intestine|small intestinal]] [[polyps]] | |Colonic [[imaging]] showing the [[Small intestine|small intestinal]] [[polyps]] | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|[[Porphyria cutanea tarda]] | |[[Porphyria cutanea tarda]] | ||
| - | | - | ||
Line 154: | Line 154: | ||
|High level of [[porphyrins]] in the [[urine]] | |High level of [[porphyrins]] in the [[urine]] | ||
| | | | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|Salt-depletion [[nephritis]] | |Salt-depletion [[nephritis]] | ||
| + | | + | ||
Line 171: | Line 171: | ||
|<15:1 [[BUN-to-creatinine ratio|BUN:CR]] | |<15:1 [[BUN-to-creatinine ratio|BUN:CR]] | ||
| | | | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|[[Bronchogenic carcinoma]] | |[[Bronchogenic carcinoma]] | ||
| - | | - | ||
Line 188: | Line 188: | ||
[[Hypokalemia]] | [[Hypokalemia]] | ||
|[[Cytological]] or [[histological]] [[evidence]] of [[lung cancer]] in [[sputum]], [[pleural fluid]], or tissue | |[[Cytological]] or [[histological]] [[evidence]] of [[lung cancer]] in [[sputum]], [[pleural fluid]], or tissue | ||
|-style="background: #DCDCDC; padding: 5px; text-align: center;" | |- style="background: #DCDCDC; padding: 5px; text-align: center;" | ||
|[[Anorexia nervosa]] | |[[Anorexia nervosa]] | ||
| + | | + | ||
Line 204: | Line 204: | ||
|[[Psychiatric]] condition | |[[Psychiatric]] condition | ||
|} | |} | ||
[[Addison's disease]] should be differentiated from other diseases causing secondary [[Adrenal insufficiency (patient information)|adrenal insufficiency]] due to [[hypopituitarism]].<ref name="pmid9541295">{{cite journal |vauthors=Sato N, Sze G, Endo K |title=Hypophysitis: endocrinologic and dynamic MR findings |journal=AJNR Am J Neuroradiol |volume=19 |issue=3 |pages=439–44 |year=1998 |pmid=9541295 |doi= |url=}}</ref><ref name="pmid7758238">{{cite journal |vauthors=Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH |title=Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature |journal=Clin. Endocrinol. (Oxf) |volume=42 |issue=3 |pages=315–22 |year=1995 |pmid=7758238 |doi= |url=}}</ref><ref name="pmid26262437">{{cite journal |vauthors=Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S |title=Diagnosis of Primary Hypophysitis in Germany |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=10 |pages=3841–9 |year=2015 |pmid=26262437 |doi=10.1210/jc.2015-2152 |url=}}</ref><ref name="pmid7629223">{{cite journal |vauthors=Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S |title=Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings |journal=J. Clin. Endocrinol. Metab. |volume=80 |issue=8 |pages=2302–11 |year=1995 |pmid=7629223 |doi=10.1210/jcem.80.8.7629223 |url=}}</ref><ref name="pmid8345854">{{cite journal |vauthors=Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H |title=Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus |journal=N. Engl. J. Med. |volume=329 |issue=10 |pages=683–9 |year=1993 |pmid=8345854 |doi=10.1056/NEJM199309023291002 |url=}}</ref><ref name="pmid21668725">{{cite journal |vauthors=Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS |title=Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman |journal=Emerg Med Australas |volume=23 |issue=3 |pages=372–5 |year=2011 |pmid=21668725 |doi=10.1111/j.1742-6723.2011.01425.x |url=}}</ref><ref name="pmid9747750">{{cite journal |vauthors=Dejager S, Gerber S, Foubert L, Turpin G |title=Sheehan's syndrome: differential diagnosis in the acute phase |journal=J. Intern. Med. |volume=244 |issue=3 |pages=261–6 |year=1998 |pmid=9747750 |doi= |url=}}</ref> | |||
<small> | |||
{| class="wikitable" | |||
! style="background: #4479BA; width: 200px;" rowspan="3" | {{fontcolor|#FFF|Diseases}} | |||
! style="background: #4479BA; width: 200px;" rowspan="3" | {{fontcolor|#FFF|Onset}} | |||
! style="background: #4479BA; width: 200px;" colspan="5" | {{fontcolor|#FFF|Manifestations}} | |||
! style="background: #4479BA; width: 200px;" colspan="4" | {{fontcolor|#FFF|Diagnosis}} | |||
|- | |||
! style="background: #4479BA; width: 200px;" colspan="4" | {{fontcolor|#FFF|History and Symptoms}} | |||
! style="background: #4479BA; width: 200px;" rowspan="2" | {{fontcolor|#FFF|Physical examination}} | |||
! style="background: #4479BA; width: 200px;" rowspan="2" | {{fontcolor|#FFF|Laboratory findings}} | |||
! style="background: #4479BA; width: 200px;" rowspan="2" | {{fontcolor|#FFF|Gold standard}} | |||
! style="background: #4479BA; width: 200px;" rowspan="2" | {{fontcolor|#FFF| Imaging}} | |||
! style="background: #4479BA; width: 200px;" rowspan="2" | {{fontcolor|#FFF|Other investigation findings}} | |||
|- | |||
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Trumatic delivery}} | |||
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Lactation failure}} | |||
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Menstrual irregularities}} | |||
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Other features}} | |||
|- | |||
![[Sheehan's syndrome]] | |||
|Acute | |||
|<nowiki>++</nowiki> | |||
| ++ | |||
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]] | |||
|Symptoms of: | |||
* [[Adrenal insufficiency]] | |||
* [[Hypothyroidism]] | |||
| | |||
* [[Breast tissue]] [[atrophy]] | |||
* Decreased [[axillary]] and [[pubic]] hair growth | |||
| | |||
* [[Pancytopenia]] | |||
* [[Eosinophilia]] | |||
* [[Hyponatremia]] | |||
* Low [[fasting plasma glucose]] | |||
* Decreased levels of [[anterior pituitary]] [[hormones]] in blood | |||
| | |||
* Clinical diagnosis | |||
* Most senitive test: Low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]] | |||
|CT/MRI: | |||
* Sequential changes of pituitary enlargement followed by: | |||
* Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]] | |||
| | |||
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests) | |||
|- | |||
![[Lymphocytic hypophysitis]] | |||
|Acute | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+</nowiki> | |||
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]] | |||
| | |||
* Associated with [[autoimmune]] conditions | |||
* Generalized [[headache]] | |||
* Retro-orbital or Bitemporal [[pain]] | |||
* Mass lesion effect such as [[Visual field defect|visual field defects]] | |||
| | |||
* [[Diabetes insipidus|DI]] | |||
* [[Autoimmune]] [[thyroiditis]] | |||
| | |||
* Decreased pituitary hormones([[Gonadotropins]] most common) | |||
* [[Hyperprolactinemia]](40%) | |||
* [[Growth hormone|GH]] excess | |||
| | |||
* [[Pituitary gland|Pituitary]] [[biopsy]]: [[lymphocytic]] [[Infiltration (medical)|infiltration]] | |||
| | |||
* [[CT]] & [[MRI]]: Features of a [[Pituitary gland|pituitary]] [[mass]] | |||
* Diffuse and homogeneous contrast enhancement | |||
|[[Assay|Assays]] for: | |||
* Anti-TPO | |||
* Anti-Tg Ab | |||
|- | |||
![[Pituitary apoplexy]] | |||
|Acute | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>++</nowiki> | |||
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]] | |||
|Severe [[headache]] | |||
* [[Nausea and vomiting]] | |||
* Paralysis of eye muscles ([[diplopia]]) | |||
* Changes in vision | |||
| | |||
* [[Visual acuity]] defects | |||
* [[Cranial nerve palsies|CN palsies]] (nerves III, IV, V , and VI) | |||
| | |||
* Decreased levels of [[anterior]] pituitary hormones in blood. | |||
| | |||
* [[Magnetic resonance imaging|MRI]] | |||
| | |||
* [[CT]] scan without [[Contrast medium|contrast]]: Hemorrhag<nowiki/>e on [[CT]] presents as a hyperdense lesion | |||
* [[MRI]]: If inconclusive [[CT]] | |||
| | |||
[[Blood tests]] may be done to check: | |||
* [[PT]]/[[INR]] and [[aPTT]] | |||
* [[Pituitary gland|Pituitary]] [[hormonal]] assay | |||
|- | |||
![[Empty sella syndrome]] | |||
|Chronic | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+</nowiki> | |||
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]] | |||
| | |||
* [[Erectile dysfunction]] | |||
* [[Headache]] | |||
* Low [[libido]] | |||
| | |||
* Signs of raised [[intracranial pressure]] may be present | |||
* [[Nipple discharge|Nipple]] discharge | |||
| | |||
* Decreased levels of pituitary hormones in blood. | |||
| | |||
* [[MRI]] | |||
| | |||
* [[Empty sella]] containing [[Cerebrospinal fluid|CSF]] | |||
| | |||
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests) | |||
|- | |||
![[Simmond's Disease|Simmonds' disease]]/[[Pituitary]] [[cachexia]] | |||
|Chronic | |||
|<nowiki>+/-</nowiki> | |||
| + | |||
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]] | |||
| | |||
* [[Cachexia]] | |||
* [[Premature aging|Premature]] aging | |||
| | |||
* Progressive [[emaciation]] | |||
* Loss of body hair | |||
| | |||
* Decreased levels of anterior pituitary hormones in blood. | |||
| | |||
* [[Magnetic resonance imaging|MRI]] | |||
| | |||
* Done to rule out any pituitary cause | |||
| | |||
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests) | |||
|- | |||
! [[Primary hypothyroidism|Hypothyroidism]] | |||
|Chronic | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|[[Oligomenorrhea]]/[[menorrhagia]] | |||
| | |||
* Cold intolerance | |||
* [[Constipation]] | |||
| | |||
* Dry skin | |||
* [[Bradycardia]] | |||
* Hair loss | |||
* [[Myxedema]] | |||
* Delayed relaxation phase of deep [[Tendon reflex|tendon reflexes]] | |||
| | |||
* Low [[T3]],[[T4]] | |||
* Normal/ low [[Thyroid-stimulating hormone|TSH]] | |||
* Rest of pituitary hormone levels WNL | |||
| | |||
* [[TSH]] levels | |||
| | |||
* Done to rule out any pituitary cause | |||
| | |||
*Assays for anti-TPO and anti-Tg Ab | |||
*FNA biopsy | |||
|- | |||
![[Hypogonadotropic hypogonadism]] | |||
|Chronic | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]] | |||
| | |||
* [[Hot flushes]] | |||
* Energy and mood changes | |||
* Decreased [[libido]] | |||
| | |||
* [[Breast tissue]] [[atrophy]] | |||
* Decreased [[maturation]] of [[vaginal]] [[mucosa]] | |||
| | |||
* Low [[estrogen]], [[testosterone]] | |||
* High [[FSH]]/[[Luteinizing hormone|LH]] | |||
| | |||
* [[FSH]] | |||
* [[Luteinizing hormone|LH]] | |||
| | |||
* Done to rule out any pituitary cause | |||
| | |||
* Genetic tests ([[karyotype]]) | |||
* Measurement of total and free [[testosterone]] and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] concentrations | |||
|- | |||
!Hypoprolactinemia | |||
|Chronic | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+</nowiki> | |||
|<nowiki>-</nowiki> | |||
| | |||
* [[Infertility]] | |||
* Subfertiliy | |||
| | |||
* Puerperal agalactogenesis | |||
| | |||
* No workup is necessary | |||
| | |||
* Decreased prolactin levels | |||
| | |||
* Done to rule out any pituitary cause | |||
| | |||
* [[Prolactin]] assay in [[3rd trimester]] | |||
* [[Luteinizing hormone|LH]], [[Follicle-stimulating hormone|FSH]] | |||
* [[Thyrotropin]] and free [[thyroxine]] | |||
|- | |||
![[Panhypopituitarism]] | |||
|Chronic | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+</nowiki> | |||
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]] | |||
| | |||
* [[Polyuria]] | |||
* [[Polydipsia]] | |||
* Features of [[hypothyroidism]] and [[hypoadrenalism]] | |||
| | |||
* [[Growth failure]] | |||
* B/L [[hemianopsia]] | |||
* [[Papilledema]] | |||
| | |||
* All pituitary hormones decreased | |||
| | |||
* [[Magnetic resonance imaging|MRI]] | |||
| | |||
* Done to rule out any pituitary cause | |||
| | |||
* Left hand and wrist [[radiograph]] for [[bone age]] | |||
|- | |||
![[Primary adrenal insufficiency]]/[[Addison's disease]] | |||
|Chronic | |||
|<nowiki>-</nowiki> | |||
| - | |||
|<nowiki>-</nowiki> | |||
| | |||
* [[Hypoglycemia]] | |||
* [[Hypotension]] | |||
| | |||
* [[Dehydration]] | |||
* [[Hyperpigmentation]] | |||
* loss of [[pubic]] and [[axillary]] hair | |||
| | |||
* [[Hyponatremia]] with/without [[hyperkalemia]] | |||
* [[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]] | |||
| | |||
* Abdominal [[Computed tomography|CT]] | |||
| | |||
* Abdominal [[Computed tomography|CT]] | |||
| | |||
* Serum [[cortisol]] testing | |||
* Serum [[ACTH]] testing | |||
* Anti-adrenal [[Antibody|Ab]] testing | |||
|- | |||
![[Menopause]] | |||
|Chronic | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]] | |||
| | |||
* [[Hot flashes]] | |||
* [[Insomnia]] | |||
* [[Weight gain]] and [[bloating]] | |||
* Mood changes | |||
| | |||
* [[Vaginal atrophy]] | |||
* Loss of pelvic [[muscle tone]] | |||
| | |||
* ↑ [[FSH]] | |||
* ↓ [[Estradiol]] and [[inhibin]] | |||
| | |||
* [[FSH]] > [[LH]] | |||
|Normal | |||
| | |||
* [[Endometrial biopsy]] | |||
|} | |||
<small> | |||
==References== | ==References== |
Latest revision as of 19:30, 25 February 2019
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Addison's disease must be differentiated from other diseases that cause hypotension, skin pigmentation, and abdominal pain such as myopathies, celiac disease, Peutz-Jeghers syndrome, anorexia nervosa, syndrome of inappropriate antidiuretic hormone (SIADH), neurofibromatosis, porphyria cutanea tarda, salt-depletion nephritis and bronchogenic carcinoma.
Differentiating Addison's disease from other Diseases
Addison's disease (primary adrenal insufficiency) must be first differentiated from secondary and tertiary adrenal insufficiency as all the three of them present with similar symptoms due to cortisol and mineralocorticoid hormone deficiencies.
- Serum ACTH level can help distinguish primary from secondary/tertiary adrenal insufficiency
Type of
Adrenal insufficiency |
Skin Pigmentation | ACTH | Normal ACTH |
---|---|---|---|
Addison disease | + | >60 ng/mL | 5-30 ng/mL |
Secondary /
tertiary adrenal insufficiency |
- | <5 ng/mL |
Addison's disease must be differentiated from other diseases that cause hypotension, skin pigmentation, muscle weakness and abdominal pain which include myopathies, celiac disease, Peutz-Jeghers syndrome, anorexia nervosa, syndrome of inappropriate antidiuretic hormone (SIADH), neurofibromatosis, porphyria cutanea tarda, salt-depletion nephritis and bronchogenic carcinoma.[1][2][3][4][5]
Disease | Differentiating symptoms | Differentiating laboratory findings | Gold standard test | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Hypotension | Abdominal pain | Anorexia/
weight loss |
Muscle weakness | Hypoglycemia | Skin pigmentation | Other symptoms | Hyponatremia | Cortisol levels | Other labs | ||
Addison's disease | + | + | + | + | + | + | + | Low | ACTH stimulation test | ||
Myopathies
hereditary myopathies) |
- | - | - | + | - | Heliotrope rash and
Gottron's sign |
- | Normal | - | Muscle biopsy | |
Celiac disease | - | + | + | - | - | Dermatitis herpetiformis |
|
- | Normal | - | Abnormal small bowel biopsy |
Syndrome of inappropriate anti-diuretic hormone | - | - | - | - | - | - | - | + | Normal |
|
Water deprivation test |
Neurofibromatosis | - | - | + | + | - | Axillary- and inguinal-area freckling |
|
- | - | - | Biopsy of skin tissue |
Peutz-Jeghers syndrome | + | + |
|
- | Normal | Colonic imaging showing the small intestinal polyps | |||||
Porphyria cutanea tarda | - | + | - | - | - | Blisters on sun-exposed sites |
|
- | Normal or elevated | High level of porphyrins in the urine | |
Salt-depletion nephritis | + | Flank pain | - | - | - | - | + | Elevated | <15:1 BUN:CR | ||
Bronchogenic carcinoma | - | - | + | - | - | + | - | Elevated | Increased ACTH and | Cytological or histological evidence of lung cancer in sputum, pleural fluid, or tissue | |
Anorexia nervosa | + | - | + | + | + | - |
|
- | Elevated | - | Psychiatric condition |
Addison's disease should be differentiated from other diseases causing secondary adrenal insufficiency due to hypopituitarism.[6][7][8][9][10][11][12]
Diseases | Onset | Manifestations | Diagnosis | |||||||
---|---|---|---|---|---|---|---|---|---|---|
History and Symptoms | Physical examination | Laboratory findings | Gold standard | Imaging | Other investigation findings | |||||
Trumatic delivery | Lactation failure | Menstrual irregularities | Other features | |||||||
Sheehan's syndrome | Acute | ++ | ++ | Oligo/amenorrhea | Symptoms of: |
|
|
CT/MRI:
|
| |
Lymphocytic hypophysitis | Acute | +/- | + | Oligo/amenorrhea |
|
|
|
Assays for:
| ||
Pituitary apoplexy | Acute | +/- | ++ | Oligo/amenorrhea | Severe headache
|
|
|
Blood tests may be done to check: | ||
Empty sella syndrome | Chronic | - | + | Oligo/amenorrhea |
|
|
|
|
| |
Simmonds' disease/Pituitary cachexia | Chronic | +/- | + | Oligo/amenorrhea |
|
|
|
| ||
Hypothyroidism | Chronic | +/- | - | Oligomenorrhea/menorrhagia |
|
|
|
|
|
|
Hypogonadotropic hypogonadism | Chronic | - | - | Oligo/amenorrhea |
|
|
|
|
| |
Hypoprolactinemia | Chronic | - | + | - |
|
|
|
|
|
|
Panhypopituitarism | Chronic | - | + | Oligo/amenorrhea |
|
|
|
|
| |
Primary adrenal insufficiency/Addison's disease | Chronic | - | - | - |
|
|
|
| ||
Menopause | Chronic | - | +/- | Oligo/amenorrhea |
|
|
Normal |
References
- ↑ Selva-O'Callaghan A, Labrador-Horrillo M, Gallardo E, Herruzo A, Grau-Junyent JM, Vilardell-Tarres M (2006). "Muscle inflammation, autoimmune Addison's disease and sarcoidosis in a patient with dysferlin deficiency". Neuromuscul. Disord. 16 (3): 208–9. doi:10.1016/j.nmd.2006.01.005. PMID 16483775.
- ↑ Kumar V, Rajadhyaksha M, Wortsman J (2001). "Celiac disease-associated autoimmune endocrinopathies". Clin. Diagn. Lab. Immunol. 8 (4): 678–85. doi:10.1128/CDLI.8.4.678-685.2001. PMC 96126. PMID 11427410.
- ↑ Adams R, Hinkebein MK, McQuillen M, Sutherland S, El Asyouty S, Lippmann S (1998). "Prompt differentiation of Addison's disease from anorexia nervosa during weight loss and vomiting". South. Med. J. 91 (2): 208–11. PMID 9496878.
- ↑ Lever EG, Stansfeld SA (1983). "Addison's disease, psychosis, and the syndrome of inappropriate secretion of antidiuretic hormone". Br J Psychiatry. 143: 406–10. PMID 6414566.
- ↑ BELL R, PATTEE CJ (1956). "Addison's disease associated with neurofibromatosis". Can Med Assoc J. 75 (5): 415–7. PMC 1823303. PMID 13356214.
- ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
- ↑ Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH (1995). "Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature". Clin. Endocrinol. (Oxf). 42 (3): 315–22. PMID 7758238.
- ↑ Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S (2015). "Diagnosis of Primary Hypophysitis in Germany". J. Clin. Endocrinol. Metab. 100 (10): 3841–9. doi:10.1210/jc.2015-2152. PMID 26262437.
- ↑ Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S (1995). "Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings". J. Clin. Endocrinol. Metab. 80 (8): 2302–11. doi:10.1210/jcem.80.8.7629223. PMID 7629223.
- ↑ Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H (1993). "Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus". N. Engl. J. Med. 329 (10): 683–9. doi:10.1056/NEJM199309023291002. PMID 8345854.
- ↑ Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS (2011). "Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman". Emerg Med Australas. 23 (3): 372–5. doi:10.1111/j.1742-6723.2011.01425.x. PMID 21668725.
- ↑ Dejager S, Gerber S, Foubert L, Turpin G (1998). "Sheehan's syndrome: differential diagnosis in the acute phase". J. Intern. Med. 244 (3): 261–6. PMID 9747750.