UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Clinical manifestations of adrenal insufficiency in adults

Author
Lynnette K Nieman, MD
Section Editor
André Lacroix, MD
Deputy Editor
Kathryn A Martin, MD

INTRODUCTION

The symptoms and signs of adrenal insufficiency depend upon the rate and extent of loss of adrenal function, whether mineralocorticoid production is preserved, and the degree of stress. The onset of adrenal insufficiency is often very gradual, and it may go undetected until an illness or other stress precipitates adrenal crisis.

The acute and chronic clinical manifestations of adrenal insufficiency in adults are reviewed here. The causes, diagnosis, and treatment of the different forms of adrenal insufficiency are reviewed separately. (See "Causes of primary adrenal insufficiency (Addison's disease)" and "Causes of secondary and tertiary adrenal insufficiency in adults" and "Diagnosis of adrenal insufficiency in adults" and "Treatment of adrenal insufficiency in adults".)

ADRENAL CRISIS

Clinical settings — The syndrome of adrenal crisis (acute adrenal insufficiency) in adults may occur in the following situations:

In a previously undiagnosed patient with primary adrenal insufficiency who has been subjected to serious infection or other acute, major stress.

In a patient with known primary adrenal insufficiency who does not take more glucocorticoid during an infection or other major illness or has persistent vomiting caused by viral gastroenteritis or other gastrointestinal disorders. (See "Treatment of adrenal insufficiency in adults", section on 'Emergency precautions'.)

                               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Nov 04 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Piédrola G, Casado JL, López E, et al. Clinical features of adrenal insufficiency in patients with acquired immunodeficiency syndrome. Clin Endocrinol (Oxf) 1996; 45:97.
  2. Jacobs TP, Whitlock RT, Edsall J, Holub DA. Addisonian crisis while taking high-dose glucocorticoids. An unusual presentation of primary adrenal failure in two patients with underlying inflammatory diseases. JAMA 1988; 260:2082.
  3. Cronin CC, Callaghan N, Kearney PJ, et al. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med 1997; 157:456.
  4. Saruta T, Suzuki H, Handa M, et al. Multiple factors contribute to the pathogenesis of hypertension in Cushing's syndrome. J Clin Endocrinol Metab 1986; 62:275.
  5. Ohtani R, Yayama K, Takano M, et al. Stimulation of angiotensinogen production in primary cultures of rat hepatocytes by glucocorticoid, cyclic adenosine 3',5'-monophosphate, and interleukin-6. Endocrinology 1992; 130:1331.
  6. Jeremy JY, Dandona P. Inhibition by hydrocortisone of prostacyclin synthesis by rat aorta and its reversal with RU486. Endocrinology 1986; 119:661.
  7. Burke CW. Adrenocortical insufficiency. Clin Endocrinol Metab 1985; 14:947.
  8. Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D. Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases. Medicine (Baltimore) 1982; 61:13.
  9. Andrioli M, Pecori Giraldi F, Cavagnini F. Isolated corticotrophin deficiency. Pituitary 2006; 9:289.
  10. Cambiaso P, Schiaffini R, Pontrelli G, et al. Nocturnal hypoglycaemia in ACTH and GH deficient children: role of continuous glucose monitoring. Clin Endocrinol (Oxf) 2013; 79:232.
  11. Bouachour G, Tirot P, Varache N, et al. Hemodynamic changes in acute adrenal insufficiency. Intensive Care Med 1994; 20:138.
  12. Tucker WS Jr, Niblack GD, McLean RH, et al. Serositis with autoimmune endocrinopathy: clinical and immunogenetic features. Medicine (Baltimore) 1987; 66:138.
  13. Castaldo ET, Guillamondegui OD, Greco JA 3rd, et al. Are adrenal injuries predictive of adrenal insufficiency in patients sustaining blunt trauma? Am Surg 2008; 74:262.
  14. Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med 1989; 110:227.
  15. Xarli VP, Steele AA, Davis PJ, et al. Adrenal hemorrhage in the adult. Medicine (Baltimore) 1978; 57:211.
  16. Warkentin TE, Safyan EL, Linkins LA. Heparin-induced thrombocytopenia presenting as bilateral adrenal hemorrhages. N Engl J Med 2015; 372:492.
  17. Streeten DHP. Adrenal hemorrhage. Endocrinologist 1996; 6:277.
  18. Migeon CJ, Kenny FM, Hung W, Voorhess ML. Study of adrenal function in children with meningitis. Pediatrics 1967; 40:163.
  19. Varon J, Chen K, Sternbach GL. Rupert Waterhouse and Carl Friderichsen: adrenal apoplexy. J Emerg Med 1998; 16:643.
  20. MARGARETTEN W, NAKAI H, LANDING BH. Septicemic adrenal hemorrhage. Am J Dis Child 1963; 105:346.
  21. Adem PV, Montgomery CP, Husain AN, et al. Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children. N Engl J Med 2005; 353:1245.
  22. Tormos LM, Schandl CA. The significance of adrenal hemorrhage: undiagnosed Waterhouse-Friderichsen syndrome, a case series. J Forensic Sci 2013; 58:1071.
  23. Randeva HS, Schoebel J, Byrne J, et al. Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinol (Oxf) 1999; 51:181.
  24. Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol 2015; 3:216.
  25. Erichsen MM, Løvås K, Skinningsrud B, et al. Clinical, immunological, and genetic features of autoimmune primary adrenal insufficiency: observations from a Norwegian registry. J Clin Endocrinol Metab 2009; 94:4882.
  26. Mitchell AL, Pearce SH. Autoimmune Addison disease: pathophysiology and genetic complexity. Nat Rev Endocrinol 2012; 8:306.
  27. DUNLOP D. EIGHTY-SIX CASES OF ADDISON'S DISEASE. Br Med J 1963; 2:887.
  28. Bleicken B, Hahner S, Ventz M, Quinkler M. Delayed diagnosis of adrenal insufficiency is common: a cross-sectional study in 216 patients. Am J Med Sci 2010; 339:525.
  29. JARVIS JL, JENKINS D, SOSMAN MC, THORN GW. Roentgenologic observations in Addison's disease; a review of 120 cases. Radiology 1954; 62:16.
  30. Valenzuela GA, Smalley WE, Schain DC, et al. Reversibility of gastric dysmotility in cortisol deficiency. Am J Gastroenterol 1987; 82:1066.
  31. Tobin MV, Aldridge SA, Morris AI, et al. Gastrointestinal manifestations of Addison's disease. Am J Gastroenterol 1989; 84:1302.
  32. McBrien, DJ, Jones, RV, Creamer, B. Steatorrhoea in Addison's disease. Lancet 1963; 1:25.
  33. Irvine WJ, Barnes EW. Adrenocortical insufficiency. Clin Endocrinol Metab 1972; 1:549.
  34. Ebinger G, Six R, Bruyland M, Somers G. Flexion contractures: a forgotten symptom in Addison's disease and hypopituitarism. Lancet 1986; 2:858.
  35. Shapiro MS, Trebich C, Shilo L, Shenkman L. Myalgias and muscle contractures as the presenting signs of Addison's disease. Postgrad Med J 1988; 64:222.
  36. Leigh H, Kramer SI. The psychiatric manifestations of endocrine disease. Adv Intern Med 1984; 29:413.
  37. Anglin RE, Rosebush PI, Mazurek MF. The neuropsychiatric profile of Addison's disease: revisiting a forgotten phenomenon. J Neuropsychiatry Clin Neurosci 2006; 18:450.
  38. Letizia C, Centanni M, Scuro L, et al. High plasma levels of endothelin-1 in untreated Addison's disease. Eur J Endocrinol 1996; 135:696.
  39. Letizia C, Cerci S, Centanni M, et al. Circulating levels of adrenomedullin in patients with Addison's disease before and after corticosteroid treatment. Clin Endocrinol (Oxf) 1998; 48:145.
  40. Zuckerman-Levin N, Tiosano D, Eisenhofer G, et al. The importance of adrenocortical glucocorticoids for adrenomedullary and physiological response to stress: a study in isolated glucocorticoid deficiency. J Clin Endocrinol Metab 2001; 86:5920.
  41. Barnett AH, Espiner EA, Donald RA. Patients presenting with Addison's disease need not be pigmented. Postgrad Med J 1982; 58:690.
  42. Barkan A, Glantz I. Calcification of auricular cartilages in patients with hypopituitarism. J Clin Endocrinol Metab 1982; 55:354.
  43. Calvo Catalá J, Hortelano Martínez E, González-Cruz Cervellera MI, et al. [Calcification of auricular cartilages in a patient with adrenal insufficiency: presentation of a case and review of the literature]. An Med Interna 1994; 11:496.
  44. Zelissen PM, Bast EJ, Croughs RJ. Associated autoimmunity in Addison's disease. J Autoimmun 1995; 8:121.
  45. Ferre EM, Rose SR, Rosenzweig SD, et al. Redefined clinical features and diagnostic criteria in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. JCI Insight 2016; 1.
  46. Kahaly GJ. Polyglandular autoimmune syndromes. Eur J Endocrinol 2009; 161:11.
  47. Ahn SW, Kim TY, Lee S, et al. Adrenal insufficiency presenting as hypercalcemia and acute kidney injury. Int Med Case Rep J 2016; 9:223.
  48. Armstrong L, Bell PM. Addison's disease presenting as reduced insulin requirement in insulin dependent diabetes. BMJ 1996; 312:1601.
  49. THORN GW, FORSHAM PH. A test for adrenal cortical insufficiency; the response to pituitary andrenocorticotropic hormone. J Am Med Assoc 1948; 137:1005.
  50. Spry C. Eosinophilia in Addison's disease. Yale J Biol Med 1976; 49:411.
  51. Skiest DJ, Keiser P. Clinical significance of eosinophilia in HIV-infected individuals. Am J Med 1997; 102:449.
  52. Oboni JB, Marques-Vidal P, Pralong F, Waeber G. Predictive factors of adrenal insufficiency in patients admitted to acute medical wards: a case control study. BMC Endocr Disord 2013; 13:3.
  53. Chrousos GP, Zapanti ED. Hypothalamic-pituitary-adrenal axis in HIV infection and disease. Endocrinol Metab Clin North Am 2014; 43:791.
  54. Charmandari E, Nicolaides NC, Chrousos GP. Adrenal insufficiency. Lancet 2014; 383:2152.
  55. Cuesta M, Garrahy A, Slattery D, et al. The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study. Clin Endocrinol (Oxf) 2016.
  56. Todd GR, Acerini CL, Ross-Russell R, et al. Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom. Arch Dis Child 2002; 87:457.