Adrenal Insufficiency

BY: GROUP 2
CARLOS
DAVID
GARCIA
LIWANAG

Adrenal Gland

Adrenal glands are two small glands

located superior to the kidneys.
adrenal medulla (inner part) produces
catecholamines.
adrenal cortex (outer part) secretes
three classes of steroid hormones:
mineralocorticoids, glucocorticoids and
androgens.

Case:

Summary of the Case

A 63-year old woman presented with increasing

darkening of the skin, dizziness, and easy fatiguability,
nausea with occasional vomiting and progressive weight
loss over eight months prior to presentation. Laboratory
investigations and results are as follows: plasma cortisol
was undetectable, plasma rennin and aldosterone
activity could not be estimated. HIV screening was
negative (HIV 1& 2). A computerised tomography scan
(CT) of the abdomen showed a non-enhancing oval
shaped left suprarenal mass with calcification.

Adrenal insufficiency

Adrenal insufficiency is a condition in

which the adrenal glands do not produce
adequate amounts of steroid hormones,
primarily cortisol.
Adrenal insufficiency results from a
primary adrenal disorder or is secondary
to ACTH deficiency.

Addisons disease, the common term for

primary adrenal insufficiency, occurs when
the adrenal glands are damaged and
cannot produce enough of the adrenal
hormone cortisol.
Secondary adrenal insufficiency occurs
when the pituitary gland to produce
enough adrenocorticotropin (ACTH), a
hormone that stimulates the adrenal
glands to produce the hormone cortisol.

Secondary adrenal insufficiency is much

more common than Addisons disease.
Hormonal results:
Low baseline cortisol levels and an
elevated ACTH greater than 200 pg/ml are
suggestive of adrenal primary insufficiency
Lower serum concentrations of ACTH and
cortisol are consistent with secondary
adrenal failure.

Signs and symptoms

major cause of adrenal

insufficiency.
Primary Adrenal Insufficiency
Autoimmune Disorders
Primary adrenal insufficiency occurs when at
least 90 percent of the adrenal cortex has
been destroyed.1 As a result, both cortisol
and aldosterone are often lacking.
Sometimes only the adrenal glands are
affected. Sometimes other endocrine glands
are affected as well, as in polyendocrine
deficiency syndrome.

Secondary Adrenal Insufficiency

Stoppage of Corticosteroid Medication
Corticosteroids are often prescribed to treat
inflammatory illnesses such as rheumatoid
arthritis, asthma, and ulcerative colitis
the prescription doses often cause higher
levels than those normally achieved by the
glucocorticoid hormones created by the
body.

Once the prescription doses of

corticosteroid are stopped, the adrenal
glands may be slow to restart their
production of the bodys glucocorticoids.
To give the adrenal glands time to regain
function and prevent adrenal
insufficiency

the difference between primary and secondary

adrenal insufficiency based on the following:
Serum aldosterone, serum ACTH/cortisol, signs
and symptoms
Primary Adrenal
Insufficiency

Secondary Adrenal
Insufficiency

Serum aldosterone

Low

Normal

serum ACTH/cortisol

High ACTH (>200

pg/ml), low baseline
cortisol (8 am)

Low

signs and symptoms

Hyperpigmentation
Hyperkalemia
Hypotension
Hyponatremia

Absence of
hyperpigmentation
Less severe
hypotension

. Different tests/ methods for

the diagnosis of adrenal
insufficiency.

ATCH stimulation test

Aka. Corsyntropin stimulation test
A synthetic stimulator of cortisol and aldosterone
secretion
It test the capacity of the adrenal gland to increase
hormone production in response to stimulation
It differentiates secondary adrenal insufficiency
from tertiary adrenal insufficiency
Specimen: Rando blood specimen
Normal value: cortisol >18-20ug/dL (500-550
nmol/L)

Insulin tolerance test

Gold standard for secondary and tertiary
hypocorticolism
Confirms borderline response to ACTH stimulation
test
Requirement: adequate hypoglycemia must be
attained (serum glucose <40mg/dL)
Oral dose: 0.05 U/kg of insulin
Blood collection: 120 minutes following insulin
administration
Measure serum cortisol and glucose
Normal value: increased plasma cortisol 18 g/L
or 20 g/L at any time during the test

Metyrapone test
A confirmatory test for secondary causes of
adrenal insufficiency
Oral dose of 30 mg of metyrapone administered
orally at midnight
It measures the ability of the pituitary gland to
respond to declining levels of circulating cortisol,
thereby secrete ACTH
Performed when ATCH stimulator test is gives
normal results
Blood collection: blood collected the following day
at 8am
Normal value: elevated plasma 11-deoxycortisol
>7 g/dL (200 nmol/L)

References:
Bishops Clinical Chemistry: Principles,
techniques and correlations
niddk.nih.gov/ Adrenal Insufficiency