Adrenal Insufficiency

Kidney and adrenal gland

Adrenal insufficiency is caused by the failure of the adrenal glands to produce sufficient (or any) amounts of cortisol and aldosterone. Prolonged lack of cortisol leads to severe fatigue, chronic exhaustion, depression, loss of appetite and weight loss.It is an often elusive diagnosis that requires awareness, knowledge of symptoms and signs and endocrinological expertise to be correctly diagnosed and adequately treated. The condition occurs with a frequency of 110- 120 cases per million persons.

Lack of aldosterone leads to a drop in blood pressure, particularly when standing up quickly, and to disturbed salt levels in the blood. Sometimes patients also describe a craving for salty food. Loss of DHEA production by the adrenals results in loss of hair in pubic and underarm areas and also potentially reduced sex drive and low energy levels in women affected by adrenal insufficiency.  

Causes

Adrenal insufficiency, or Addison disease, has many causes, the most common of which is autoimmune adrenalitis. Autoimmune adrenalitis results from destruction of the adrenal cortex, which leads to deficiencies in glucocorticoids, mineralocorticoids, and adrenal androgens. Adrenal insufficiency can be described as primary, secondary or tertiary depending on the cause of the condition. Primary adrenal insufficiency (Addison’s disease) occurs when the adrenal cortex has been destroyed. There are different causes for primary adrenal insufficiency but 70–90 per cent of cases are due to an autoimmune disorder. The body’s own immune system attacks the outer layer (cortex) of the adrenal glands; it is not known why the body acts in this way.

Symptoms

Clinical signs and symptoms of adrenal insufficiency usually develop gradually and  include :

Discolouration of the skin

Dehydration

Appetite loss, unintentional weight loss

Salt, soy sauce or licorice cravings

Sore/painful, weak muscles and joints

No energy or motivation (fatigue, lethargy), low mood

Diagnosis

The diagnosis of adrenal insufficiency demands the synthesis of medical history with physical examination, substantiated by appropriate laboratory measurements and tests.

  • Consider the patient’s symptoms and examine the skin for discoloration
  • Review the patient’s medical records and inquire about a family history of other autoimmune conditions
  • Observe the patient’s blood pressure from a sitting and standing position, to see if they are suffering from postural hypotension
  • Prescribe blood tests to check a patient’s levels and low sodium, high potassium or low cortisol might be indicative of adrenal insufficiency

Treatment

Once diagnosed with adrenal insufficiency, most patients will need to take medicines on a daily basis. This is because most cases could not be cured, therefore, the condition needs to be managed and continuous treatment is required.

  • The mainstay of any treatment for adrenal insufficiency is a substitution with glucocorticosteroids. Patients with additional mineral corticosteroid deficiency might require fludrocortisone acetate.
  • Emergency situations with sufficient clinical suspicion require treatment prior to definitive laboratory confirmation or consultation of an endocrinologist but after securing blood samples.

Practise This Question

The central canal inside the spinal cord in the upper part, is continuous with the ______.