• External → adrenalectomy, chronic corticosteroid Tx
• Destructive internal process
• Autoimmune (most common) → Sporadic, Autoimmune polyendocrine, familial
• Metastasis (SMLungCa, Breast Ca)
• Infection
• Waterhouse-Friderichsen syndrome (meningococcal septicaemia)
• Tuberculosis + other infections
• Genetic - Congenital (adrenal hyperplasia → 21-hydrox-def) ⇒ see later extra!!

1. Hyperpigmentation (sun exposed + pressure, new scars, buccal+gums after skin)
2. Fatigue, Weakness, Weightloss
3. orthostatic Hypotension (pos- Schellong test)
4. GI-disturb: nausea, vomiting, abd. pain
5. Arthralgia
6. emotional instability, depression, irritability
7. loss sec. hair in woman
8. others (related to autoimmune e.g. vitiligo)
9. Clinic of HypoNa, HyperK, metab. azidosis
1. salt craving (due to Na-loss)

1. measure serum Cortisol + ACTH → if high ACTH + low Cortisol = primary; if low ACTh = central/secondary
2. ⇒ cosyntropin (rapid ACTH-stimulation) test if uncertain i.e. in partial primary → if cortisol <500 → Adrenal insuff (normal <550) ⇒ !doesn't mean its primary! → can be secondary or iatrogenic too (due to adrenal atrophy) ⇒ only tells you that you have hypoadrenalism

• HypoNa, HyperK
• low Gluc
• inc. BUN + Crea ⇒ Volume-depletion
• Anemia + Eosinophilia
• high Renin, high ADH
• ECG → low voltage, ST-modific.

⇒ What's the etiology?

• Adrenal Autoantibodies → Anti-21-hydroxylase, Anti-17-hydroxlase 📷
• CT

→ enlarged + Calcification → tuberculosis, metastasis

→ small + atrophic → chronic autoimmune

• serological+Mibi test (i.e. tuberculosis)

• life long Glucocorticoids → Hydrocortisone, Prednisone
• Mineralcorticoid in primary → Fludrocortisone
• DHEA (Dehydroepiandrosteron) - esp. in female
• enough sodium intake!
• etiological Tx → Infektion, Autoimmune, Cancer etc.

everything should return to normal

• symptoms should disappear + hyperpigmentation should improve
• !overtreatment → cushings
• check Cortisol day curves + ACTH
• Fludrocortison → Electrolytes, BP, Plasma-Renin should be normal

• ↑ Dose of steroids during (Stress, surgery, illness)
• minor stress →incr. 3x3
• major stress (surgery) → up to 200-300mg/day
• pat education: “Don’t miss a dose!”

• Hypotension, volume depletion, shock, coma
• hyperpyrexia
• CNS depression sympt
• GI symptoms like chronic
• hypoglycemia
• weakness + muscle cramps

• Addison + stress (infection, surgery, trauma, dehydration)
• Bilateral acute adrenal hemorrhage (Waterhouse-Friedrichsen syd.)
• Congenital adrenal hyperplasia

draw blood → send to lab

Tx: immediate start with Hydrocortison i.v. + Saline + Gluc i.v.

→ don’t wait for lab results before starting Tx

• low Cortisol
• HypoNa, HyperKa, metabolic azid.
• Hypoglycemia
• Eosinophilia
• Urea+ Crea

search for etiology!

→i.e. infection?