Addison's disease

Notes

## Basic introduction

  • Addison’s disease or adrenal insufficiency is a chronic condition that results from partial or complete destruction of adrenal cortex[a]
  • It is characterized by the deficiency of glucocorticoids, androgens, estrogens and aldosterone (mineralocorticoid) among other related hormones
  • Addisonian crisis is a medical emergency that occurs as a result of acute adrenocortical insufficiency. It is precipitated by:
  • The sudden withdrawal of steroids
  • Stress
  • Sudden destruction of pituitary
  • Bilateral adrenal hemorrhage/injury
  • Patients with Addison’s disease must wear a Med Alert Tag / steroid card as they are predisposed to Addisonian crisis
  • Causes of Addison’s disease:
  • Idiopathic autoimmune disorder (about 80% of cases)
  • HIV
  • Cancer
  • TB (about 10% of cases)
  • Bilateral adrenolectomy
  • Fungal infection
  • Pituitary neoplasm
  • Steroidal withdrawal
  • Hypophysectomy
  • Secondary deposits in the adrenal gland
  • Bilateral adrenal hemorrhage
  • Sarcoidosis
  • Amyloidosis
  • Hemochromatosis

## Statistics

  • The global prevalence is 120 in a million people[b]
  • It is more prevalent in women than in men
  • The predominant age set is 30 -50 yrs.
Symptoms
  • Anorexia
  • Body hair loss
  • Craving for salt
  • Depression
  • Diarrhea
  • Fatigue
  • Hyperkalemia
  • Hyperpigmentation
  • Hypoglycemia
  • Hypernatremia
  • Hypotension
  • Irritability
  • Joint pain
  • Muscle pain
  • Muscle weakness
  • Nausea
  • Loss of libido, especially in women
  • Shock
  • Vomiting
  • Weight loss

## Symptoms of Addisonian crisis

  • Severe vomiting
  • Severe diarrhea
  • Pain in the lower back
  • Severe muscle weakness
  • Fainting
Diagnosis
  • Clinical review
  • The diagnosis is often missed (with 60% cases being diagnosed after a visit to two or more physicians)[a]
  • Random plasma cortisol level
  • Below 460nmol/L
  • Short ACTH stimulation
  • Long ACTH stimulation
  • Blood glucose
  • Complete Blood Count (CBC)
  • Electrolyte levels
  • HIV test
  • CXR (for TB)
  • Adrenal auto-antibodies
  • CT scan of adrenal glands
  • Ultrasonography of adrenal glands
Differential
  • Adrenal hemorrhage
  • Adrenal suppression due to corticosteroid therapy
  • C-17 Hydroxylase Deficiency
  • Eosinophilia
  • Haemochromatosis
  • Histoplasmosis
  • Hyperkalemia
  • Hyperthyroidism
  • Occult malignancy
  • Sarcoidosis
  • Secondary adrenal insufficiency due to pituitary or hypothalamic lesions
  • TB
Prevention
  • Not possible to prevent the disease
Reference

a. Ten, S., New, M., & Maclaren, N. (2001). Addison’s disease 2001. The Journal of Clinical Endocrinology & Metabolism, 86(7), 2909-2922

b. Willis, A. C., & Vince, F. P. (1997). The prevalence of Addison's disease in Coventry, UK. Postgraduate medical journal, 73(859), 286-288..

Management
  • Hormone replacement therapy
  • Tabs Fludrocortisone 0.05 to 0.1mg daily
  • Tabs hydrocortisone 15mg on waking up and 5mg at 6.00 pm

(Parenteral hydrocortisone is given in case of vomiting)

      OR

  • Prednisolone
  • Treatment of underlying disease(s) such as HIV and TB
  • Advise the patient to increase the salt intake in hot weather or after exercise
  • Weight control
  • Proper nutrition
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