Adrenal insufficiency is a disease that develops as a result of a deficiency in the secretion of adrenal cortex hormones - glucocorticosteroids, mineralocorticosteroids and adrenal androgens. what are the causes and symptoms of adrenal insufficiency? How is the treatment going?

Adrenal insufficiencymay be primary - then the adrenal glands are damaged, or secondary, when the hypothalamus or pituitary gland is damaged. Depending on the type of the disease process, it may be acute or chronic. It is a potentially fatal disease that can manifest itself in various ways. It is likely to be suspected in people with general weakness, lack of appetite and weight loss, unexplained syncope, hypotension, hyponatraemia, hyperkalemia and hypoglycaemia. The group of patients is dominated by women, diagnosed twice as often as in men. The average age of onset is around 40 years.

Hypoadrenocorticism: causes

The causes of primary adrenocortical insufficiency (Addison's disease) are most often the autoimmune process that destroys the cortex of this gland - the blood serum of patients often shows antibodies against adrenal cortex antigens.

Other causes of primary adrenal insufficiency include bacterial (e.g. tuberculosis), viral (e.g. HIV, cytomegaly), fungal infections, neoplasms or neoplastic metastases, poisoning, adrenal hemorrhage or haemochromatosis. Very rarely, the cause of hypoadrenocorticism is congenital or acquired steroid biosynthesis disorders.

It is worth knowing that primary adrenal insufficiency may also be one of the comorbidities in the multi-glandular autoimmune syndrome type II. In addition to primary adrenal insufficiency, there is also an autoimmune disease of the thyroid gland (most often Hashimoto's disease) and / or type 1 diabetes.

Secondary adrenal insufficiency occurs when the hypothalamus or glandular pituitary is damaged by inflammatory, degenerative, neoplastic processes, hemorrhage or trauma. It can also be the result of long-term treatment with corticosteroids.

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Adrenal insufficiency: symptoms

Clinical symptoms usually occur in patients in whom 90% of the cortex of both adrenal glands has been destroyed. Depending on the duration and severity of adrenal insufficiency, various symptoms of the disease may occur - from a completely asymptomatic course in patients not exposed to increased physical or mental stress, through weakening of muscle strength, to adrenal crises, which may cause coma.

Primary adrenal insufficiency(Addison's disease) is manifested by muscle weakness, dark skin and mucous discoloration, weight loss, vomiting and diarrhea, dehydration, low blood pressure blood pressure. In addition, impotence, infertility, and menstrual disorders and loss of pubic hair can occur in women. In advanced disease, it is also possible to experience mental changes with slowing down, mental sluggishness, sometimes even with acute psychoses. Laboratory tests show hyponatremia, hyperkalaemia, hypercalcemia, very low cortisol levels, lymphocytosis and eosinophilia. You may occasionally experience hypoglycaemia.

Secondary adrenal insufficiencyhas a milder course than primary adrenal insufficiency. It is also rarely associated with adrenal crisis. It is characterized by the presence of pale porcelain skin, non-discolored nipples and very poor pigmentation in the vulva and rectal area. Often, patients have symptoms of deficiency or absence of other trophic hormones such as TSH (there are symptoms of secondary hypothyroidism) or FSH and LH (symptoms of secondary hypogonadism).Adrenal crisisis characterized by the presence of circulatory shock with a significant drop in blood pressure, dehydration and oliguria. In addition, there may be symptoms of pseudoperitonitis, vomiting, diarrhea and fever of unknown etiology. Hypoglycaemia and metabolic acidosis are found in the blood serum.

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Adrenal insufficiency: research

Convenient blood cortisol levels in patients with adrenal insufficiency are usually low but may remain within the normal range, while in patients without adrenal insufficiency but with other severe disease, it can be very low. Therefore, the determination of cortisol levels should not be used as a basis for confirming or excluding the diagnosis of cortical insufficiencyadrenal glands.

The ACTH stimulation test is used for diagnostics. To this end, the serum cortisol concentration is determined before and 60 minutes after the administration of 0.25 mg ACTH. In primary adrenal insufficiency, the baseline cortisol level is reduced or at the lower limit of the normal range. Cortisol levels do not increase after ACTH administration. In the case of secondary adrenal insufficiency, the concentration of cortisol increases after ACTH administration. However, it should be remembered that long-term secondary adrenal insufficiency due to impaired ACTH secretion in these patients leads to adrenal cortex atrophy, and thus - a lack of cortisol synthesis and secretion.

Computed tomography and MRI of the adrenal glands may indicate the presence of neoplastic metastases.

You can also measure the concentration of ACTH in the blood serum. In the case of primary adrenal insufficiency, the concentration of ACTH is significantly increased, while in secondary forms it is reduced or at the lower limit of the normal.

In addition, immunological tests are used to detect specific anti-adrenal antibodies and imaging tests. X-ray, CT and ultrasound of the abdominal cavity may reveal calcifications in the adrenal projection after tuberculosis or adrenal mycosis.

In cases of secondary adrenal insufficiency, X-rays, MRI and CT scans of the Turkish saddle are important in order to detect neoplasms or other destructive processes in this area.

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Adrenal insufficiency: differentiation

Differential diagnosis includes diarrhea of ​​various origins, myasthenia gravis, myopathy in the course of hyperthyroidism and chronic nephritis. Other causes of hyponatraemia, hyperkalaemia, hypoglycaemia, hypotonia and weight loss should also be considered, as well as adrenal gynecological syndrome in young children.

Adrenal insufficiency: treatment

Treatment of adrenal insufficiency consists in supplementing the deficiencies of glucocorticosteroids and mineralocorticosteroids. For this purpose, cortisone or prednisone and fludrocortisone are administered. It should be remembered about a 2-3 times increase in steroid doses in patients exposed to injuries and infections or performing increased physical or mental effort. In general, androgen replacement therapy is not necessary in women. Additional treatment depends on the cause of the disease.

For the treatment of adrenal crisis caused by deficiencysteroids, 100 mg of hydrocortisone is used intravenously every 4-6 hours or an equivalent amount of synthetic glucocorticosteroid preparations (prednisone, methylprednisolone, betamethasone, dexamethasone). In addition, the patient should be administered 0.9% NaCl solution and 5% glucose solution in the amount necessary to compensate for the existing disturbances in sodium and water balance. It is worth remembering that the total volume of the administered solutions depends on the central venous pressure and blood glucose levels.

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