In primary adrenal insufficiency the adrenal glands are damaged and cannot make enough cortisol and aldosterone. In the US the most common cause is autoimmune disease, and a stress such as an infection can trigger a life-threatening adrenal crisis.
Key symptoms
- Fatigue and weakness that worsen over months
- Weight loss and poor appetite
- Nausea, vomiting and abdominal pain
- Salt craving and dizziness on standing
- Darkening of the skin
What you find on exam
- Darker skin in creases, scars, gums and lips
- Low blood pressure and a drop on standing
- Signs of dehydration
- Vitiligo or other autoimmune signs
- Confusion or shock in crisis
Tests
- Low sodium and high potassium; low glucose
- Low morning cortisol with high ACTH
- ACTH stimulation test: cortisol fails to rise
- High renin; 21-hydroxylase antibodies
Treatment basics
- Crisis: hydrocortisone 100 mg IV right away plus IV saline with dextrose; do not wait for results
- Daily hydrocortisone in split doses
- Fludrocortisone to replace aldosterone
- Sick-day rules: double or triple the dose when ill; keep an injectable hydrocortisone kit
- Medical alert ID and patient teaching
Red flags
- Low blood pressure that does not respond to fluids
- Vomiting and unable to keep steroid pills down
- Confusion, severe abdominal pain or high potassium
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.