Primary adrenal insufficiency “Addison's disease” Dr. Jeff Muigai
INTRODUCTION Addison disease is adrenocortical insufficiency due to the destruction or dysfunction of the entire adrenal cortex. It affects both glucocorticoid and mineralocorticoid function. The onset of disease usually occurs when 90% or more of both adrenal cortices are dysfunctional or destroyed .
Race : is no association with race. Sex: Idiopathic autoimmune Addison disease tends to be more common in females and children. Age: The most common age in adults is 30-50 years, but the disease could present earlier in patients with: polyglandular autoimmune syndromes, congenital adrenal hyperplasia (CAH), or if onset is due to a disorder of long- chain fatty acid metabolism.
Mortality and morbidity. Morbidity and mortality usually are due to failure or delay in making the diagnosis or a failure to institute adequate glucocorticoid and mineralocorticoid replacement. If not treated promptly, acute addisonian crisis may result in death. This may be provoked either de novo, such as by adrenal hemorrhage, or in the setting of an acute event superimposed on chronic or inadequately treated adrenocortical insufficiency.
Causes: idiopathic autoimmune adrenocortical insufficiency: - The most common cause. - It accounts for more than 80% of reported cases. - It is resulting from autoimmune atrophy, fibrosis, and lymphocytic infiltration of the adrenal cortex, usually with sparing of the adrenal medulla .
Idiopathic autoimmune Addison disease may occur in isolation or in association with other autoimmune phenomena such as: - Schmidt syndrome : The association of Addison disease and Hashimoto thyroiditis. - polyglandular autoimmune syndrome type 1: The association of Addison disease with hypoparathyroidism and mucocutaneous candidiasis. It may have an autosomal recessive mode of inheritance. It has no human leukocyte antigen (HLA) associations.
- polyglandular autoimmune syndrome type2: The association of Addison disease with type 1 diabetes mellitus and Hashimoto thyroiditis or Graves disease. It may be associated with HLA- B8 and DR-3. • Chronic granulomatous diseases: TB, sarcoidosis, histoplasmosis, blastomycosis, and cryptococcosis could involve the adrenal glands.
• malignancies: Malignant infiltration of the adrenal cortices, as with Hodgkin and non-Hodgkin lymphoma and leukemia, may cause Addison disease. Metastatic malignant disease: Bilateral involvement of the adrenal glands could occur in the setting of metastatic cancer of the lung, breast, or colon or renal cell carcinoma. • Infiltrative metabolic disorders : Amyloidosis and hemochromatosis could involve the adrenal glands and lead to primary adrenocortical insufficiency.
Acquired immunodeficiency syndrome: as a result of invasion of cytomegalovirus, Mycobacterium avium intracellulare, cryptococci, or Kaposi sarcoma. Allgrove syndrome: congenital adrenocortical unresponsiveness to ACTH typically presents in childhood with failure to thrive, features of adrenocortical insufficiency and hypoglycemia.
Drug-related causes: -Ketoconazole inhibits the adrenal cytochrome P450 steroidogenic enzymes. -Aminoglutethimide blocks the early conversion of cholesterol to pregnenolone by inhibiting the 20,22-desmolase enzyme. -Busulphan, etomidate, and trilostane inhibit or interfere with adrenal steroid biosynthesis. • abdominal irradiation .
Clinical presentation: The onset of symptoms most often is insidious and nonspecific. - Hyperpigmentation of the skin and mucous membranes often precedes all other symptoms by months to years. - It is caused by the stimulant effect of excess adrenocorticotrophic hormone (ACTH) on the melanocytes to produce melanin. on the sun- exposed areas of the skin, extensor surfaces, knuckles, elbows and knees in addition to mucous membranes; dentogingival margins and buccal areas. - vitiligo: common in autoimmune Addison disease as a result of melanocytes destruction.
Dizziness with orthostasis due to hypotension occasionally may lead to syncope. This is due to the combined effects of volume depletion, loss of the mineralocorticoid effect of aldosterone, and loss of the permissive effect of cortisol in enhancing the vasopressor effect of the catecholamines. Myalgias and flaccid muscle paralysis may occur due to hyperkalemia. progressive weakness, fatigue, poor appetite, and weight loss. gastrointestinal symptoms may include nausea, vomiting, and occasional diarrhea.
Physical examination: Physical examination in long-standing cases most often reveals increased pigmentation of the skin and mucous membranes, with or without areas of vitiligo. Patients show evidence of dehydration, hypotension, and orthostasis. Female patients may show an absence of axillary and pubic hair and decreased body hair. This is due to loss of the adrenal androgens, a major source of androgens in women.
Management: lab studies rapid ACTH stimulation test: - Blood is drawn in 2 separate tubes for baseline cortisol and aldosterone values. -Synthetic ACTH (1-24 amino acid sequence) in a dose of 250 mcg (0.25 mg) is given IM or IV. -Thirty or 60 minutes after the ACTH injection, 2 more blood samples are drawn; one for cortisol and one for aldosterone.
Interpreting rapid ACTH stimulation test: -Two criteria are necessary for diagnosis: (1) an increase in the baseline cortisol value of 7 mcg/dL or more and (2) the value must rise to 20 mcg/dL or more in 30 or 60 minutes, establishing normal adrenal glucocorticoid function. In patients with Addison disease, both cortisol and aldosterone show minimal or no change in response to ACTH. -When the results of the rapid ACTH do not meet the 2 criteria mentioned above, further testing might be required to distinguish Addison disease from secondary adrenocortical insufficiency.
In acute adrenal crisis, where treatment should not be delayed in order to do the tests, a blood sample for a random plasma cortisol level should be drawn prior to starting hydrocortisone replacement. A random plasma cortisol value of 25 mcg/dL or greater effectively excludes adrenal insufficiency of any kind.
Urea and electrolyte: - hyponatremia, hyperkalemia, and a mild non – anion-gap metabolic acidosis due to the loss of the sodium-retaining and potassium and hydrogen ion-secreting action of aldosterone. - elevated blood urea nitrogen (BUN) and creatinine due to the hypovolemia, a decreased glomerular filtration rate, and a decreased renal plasma flow. - Hypoglycemia may be present in fasted patients, or it may occur spontaneously. It is caused by the increased peripheral utilization of glucose and increased insulin sensitivity. It is more prominent in children and in patients with secondary adrenocortical insufficiency. - Urinary and sweat sodium also may be elevated.
FHG: - may reveal a normocytic normochromic anemia. • Thyroid-stimulating hormone: - Increased thyroid-stimulating hormone (TSH), with or without low thyroxine, with or without associated thyroid autoantibodies, and with or without symptoms of hypothyroidism, may occur in patients with Addison disease and in patients with secondary adrenocortical insufficiency due to isolated ACTH deficiency. These findings may be slowly reversible with cortisol replacement.
Management: imaging: Chest x-ray: - The chest x-ray often normal except in evidence of TB or fungal infection that initially cause Addison disease. • CT scan: - Abdominal CT scan may be normal but may show bilateral enlargement of the adrenal glands in patients with Addison disease because of TB, fungal infections, adrenal hemorrhage, or infiltrating diseases involving the adrenal glands. - In idiopathic autoimmune Addison disease, the adrenal glands usually are atrophic .
Histological finding: In cases due to idiopathic autoimmune adrenocortical atrophy, the adrenal glands usually are atrophic, with marked lymphocytic infiltration and fibrosis of the adrenal capsule. The adrenal medulla is spared. In cases due to TB, the adrenal glands may be enlarged and contain caseating granulomas. Diffuse calcification may be evident, and the adrenal medulla usually is involved. In patients with AIDS, the adrenal glands may show necrotizing inflammation, hemorrhage, and infarction.
Medical treatment: inpatient care In case of adrenal crisis: - IV access should be established urgently. - an infusion of isotonic sodium chloride solution should be begun to restore volume deficit and correct hypotension. Some patients may require glucose supplementation. - The precipitating cause should be sought and corrected where possible. -Administer 100 mg of hydrocortisone in 100 cc of isotonic sodium chloride solution by continuous IV infusion at a rate of 10-12 cc/h. Infusion may be initiated with 100 mg of hydrocortisone as an IV bolus.
Analysis of AVP functions via V1a and V1b receptors with knockout mice Akito Tanoue Department of Pharmacology, National Research Institute for Child Health and Development Arginine Arginine- -Vasopressin ( Vasopressin (AVP) AVP) is involved
726 views • 24 slides
The Digestive System From a Microbial Perspective Good morning! For the last 40 years Ive led a charmed life: Ive participated in a farm becoming an organism and then an ecosystem while teaching me the dynamics of bio-Logical
192 views • 8 slides
Jackie Eberstein - Presenta0on (SD 2016) Dr. Eberstein: By show of hands, how many of you are non-medical people? Oh, good, okay. So we'll
323 views • 17 slides
Perinatal Mental Health Conference Fairmont Hot Springs, Montana October 2018 Connecting Pathways and Building Bridges An Integrative Approach for Treating Perinatal Mood and Anxiety Disorders Christine White Deeble, ND
960 views • 92 slides
INTERNATIONAL STUDENT TB SCREENING IN A UNIVERSITY SETTING James R. Koski, MD, MPH OSU Student Health Services Disclosures- None TB Ward Tenwek Hospital Kenya 1988 1 Pulmonary Tuberculosis OREGON STATE UNIVERSITY 2 Latent
267 views • 22 slides
Stress Dosing of Steroid Third QPEM Conference 11-13 th of January 2019 Dr. Mahmoud Alrifaai Consultant pediatrics . PEC. Alsadd DISCLOSURE I do not have any relevant financial relationship with commercial interest to disclose. Learning
738 views • 19 slides
INTRAPARTUM FETAL HEART RATE MONITORING Definitions, Interpretation and Management Applying Principles of Patient Safety David A. Miller, M.D. Professor of Obstetrics, Gynecology and Pediatrics Division of Maternal Fetal Medicine University of
1.38k views • 69 slides
Case Presentation: An Irritable Infant With a Surprise Diagnosis Dr Mick Henderson Department Clinical Biochemistry and Immunology Leeds Teaching Hospitals Trust Presentation 2 year old female infant Presented to local DGH with 2
346 views • 16 slides
Eur J Gen Med 2016;13(2):155-157 Case Report DOI : 10.15197/ejgm.1457 Recurrent Hypoglycaemia: an Uncommon Presentation in Sheehan Syndrome HK Aggarwal 1 , Deepak Jain 1 , Sunil Pawar 1 , Anshul Mittal 1 ,Promil Jain 2 Malign Servikal Lenf
415 views • 3 slides
PGY2 Case Presentation John C Baniewicz, MD PGY2 Table of Contents - Initial Presentation - ER Work-up - Hospital Course - Discussion - Updates 2 INITIAL PRESENTATION JT is a 68-year-old female with PMH tobacco (1 pack/daily for 30
532 views • 16 slides
Measuring Animal Welfare Nadja Wielebnowski, PhD Conservation and Research Manager Oregon Zoo Zoo Animal Welfare Science: An Emerging Field Animal Welfare Committee Promoting Excellence in Animal Care Established in 2001 Formal
608 views • 27 slides
Crit Care & Shock (2011) 14:46-51 An unusual presentation of pheochromocytoma Zulmari Campos-Santiago, Juan C. Bird-Caceres, Jose M. Ortiz-Betancourt, Carmen Pimentel-Torres, Karla Torres-Torres, Maria E. Ocasio-Tascn, William
498 views • 6 slides
Diurnal Cortisol Profile as a Predictor of Weight Change over 6 years: The Multiethnic Study of Atherosclerosis (MESA) Stress Study Joshua J. Joseph, MD Endocrinology Fellow Division of Endocrinology, Diabetes and Metabolism Johns Hopkins
449 views • 26 slides
Lung Cancer Objectives To provide a general overview of lung physiology To explore the types and classifications of lung cancer To provide causes and risk factors of lung cancer To present the signs and symptoms of lung cancer in throughout
682 views • 40 slides
Comprehensive molecular analysis of recurrence in gastroesophageal adenocarcinoma PROMOREC project th Sep thology, 8 th Europea ean Con Congress of of Path ept t 2019, Nic ice F Renaud, G Piessen, M Figeac, C Dejeante, M Messier, L
659 views • 16 slides
Pattern and implication of lymphatic drainage in renal tumors Axel Bex, MD, PhD The Netherlands Cancer Institute FOIU Tel Aviv, July 4, 2018 Financial and Other Disclosures Off-label use of drugs, devices, or other agents: None or FILL IN
588 views • 19 slides
Meet the experts: Cardiogenic Shock Inotropes: effects on the heart, the microcirculation and other organs ACCA Masterclass 2017 Alessandro Sionis Director Acute & Intensive Cardiac Care Unit Hospital de la Santa Creu I Sant Pau
1.08k views • 46 slides
Adrenaline Fueled Development: Racing With Autonomous Vehicles Session: 23317 D A T E Jendrik Jrdening Anthony Navarro Data Scientist Product Lead Akka Technologies Udacity firstname.lastname@example.org email@example.com 1 7/28/17
715 views • 17 slides
4/18/2014 Learning Objectives Supporting the Special Needs of Develop an awareness about the neuroscience of learning and how that can inform the learning Gifted Children: Neuroscience process for gifted kids Implications for Regulating
693 views • 9 slides
Advanced Survival Training Mana Managing P ging Police Str lice Stress ss and and Burnout Burnout Rick Randall MS, DRS, CMBT APD Senior Chaplain and Training Specialist 1 Course Philosophy Stress plays a significant role in the health
654 views • 37 slides
AOP Summer Presentation Chief of Operations Gideon Cohen, EMT-B 1 st Assistant Chief Caroline Schwartz, EMT-B What to do in an emergency... Call 911 What happens when you call 911? University Police Ambulance Livingston County Scene 911
441 views • 12 slides
Updating medicine ingredient names International harmonisation of ingredient names Jola Samoc Project Manager Therapeutic Goods Administration IHIN@tga.gov.au ARCS webinar 10 June 2016 Overview Ingredient terminology What are the
781 views • 11 slides
Cardiac, Physiologic, and Real World Effects of Taser Use 21 June 2017 Conducted Energy Device Meeting San Francisco Police Commission Zian H. Tseng, M.D., M.A.S. Murray Davis Endowed Professor Associate Professor of Medicine in Residence
398 views • 21 slides
CE NT RAL L INE PL ACE ME NT IN T HE ICU E mily Hurst, DO, F ACOI Critic a l Ca re Me dic ine Ave ra e I CU Me dic a l Dire c to r OBJE CT IVE S 1) Re vie w I ndic a tio ns a nd Me dic a tio ns Ne c e ssita ting Ce ntra l
507 views • 50 slides