Article Figures & Data
Tables
- Box 1.
Symptoms Abdominal pain
Nausea
Myalgia
Weight loss
Fatigue
Dizziness
Hypotension/shock
Fever
Skin hyperpigmentation (primary adrenal insufficiency only)
Hyponatraemia
Hyperkalaemia
↑Urea
Metabolic acidosis
↑TSH
Hypercalcaemia (uncommon)
Hypoglycaemia (more common in children)
Lymphocytosis
Eosinophilia
- Box 2.
Primary adrenal insufficiency Autoimmune: Isolated adrenal insufficiency (Addison's), APS1 (adrenal insufficiency + hypoparathyroidism + mucocutaenous candidiasis), APS2 (adrenal insufficiency + thyroid disease [Schmidt's syndrome] + Type 1 diabetes [Carpenter's syndrome])
Infections: Tuberculosis, fungal infiltration, AIDS
Genetic: Adrenoleukodystrophy, congenital adrenal hyperplasia, adrenal hypoplasia congenita
Vascular: Adrenal infarction / haemorrhage (Waterhouse-Friedrichson syndrome in meningococcal sepsis)
Infiltrative: Metastasis, lymphoma, sarcoidosis, amyloidosis, haemachromatosis
Iatrogenic: Surgical adrenalectomy or drug induced (eg mitotate, etomidate, ketoconazole, immunotherapy)
Secondary adrenal insufficiency Tumour: Pituitary macroadenoma, other tumour (craniopharyngioma, meningioma)
Iatrogenic: Pituitary irradiation, drugs (opioids, glucocorticoids, immunotherapy)
Vascular: Apoplexy, Sheehan's syndrome
Infiltrative: Tuberculosis, sarcoidosis, histiocytosis X, granulomatosis with polyangiitis, lymphocytic hypophysitis
Trauma
Genetic
APS = autoimmune polyendocrine syndromes.
- Box 3.
For moderate illness (eg fever, infection requiring antibiotics, surgical procedure under local anaesthetic), usual oral steroid dose can be doubled up. In patients with suspected or proven COVID-19 infection, high doses of gluccocorticoid supplementation (equivalent to hydrocortisone 20 mg four times daily) should be used.
To cover severe illness, eg persistent vomiting, pneumonia, trauma or acute surgery, patients should receive an initial bolus of 100 mg IV hydrocortisone followed by 50 mg (IM or IV) hydrocortisone 6-hourly or 200 mg / 24 hour IV infusion until resolution of the illness.
For moderate elective procedures or investigations, eg endoscopy or angiography, patients should receive a single dose of 100 mg hydrocortisone before the procedure.
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