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Diagnosis of adrenal insufficiency in adults

INTRODUCTION

The clinical presentation of adrenal insufficiency is variable, depending on whether the onset is acute, leading to adrenal crisis, or chronic, with symptoms that are more insidious and vague. Therefore, the diagnosis of adrenal insufficiency depends upon a critical level of clinical suspicion. Adrenal crisis should be considered in any patient who presents with peripheral vascular collapse (vasodilatory shock), whether or not the patient is known to have adrenal insufficiency. Likewise, isolated corticotropin (ACTH) deficiency, although rare, should be considered in any patient who has unexplained severe hypoglycemia or hyponatremia. (See "Clinical manifestations of adrenal insufficiency in adults".)

GENERAL PRINCIPLES

Exogenous glucocorticoids — Prolonged administration of pharmacologic doses of synthetic glucocorticoids is by far the most common cause of ACTH deficiency and consequent adrenal insufficiency. (See "Causes of primary adrenal insufficiency (Addison's disease)" and "Causes of secondary and tertiary adrenal insufficiency in adults".)

However, patients treated with glucocorticoid therapy rarely present with adrenal crisis, although sudden withdrawal of glucocorticoids can result in exacerbation of the disorder for which they were being given (eg, asthma, inflammatory disease, or organ transplantation), symptoms of glucocorticoid deficiency, or hypotension. (See "Clinical manifestations of adrenal insufficiency in adults".)

The principles involved in weaning patients from chronic high-dose glucocorticoid therapy are discussed elsewhere. (See "Glucocorticoid withdrawal".)

Critical illness — Subnormal corticosteroid production during critical illness in the absence of structural defects in the hypothalamic-pituitary-adrenal axis has been termed "functional adrenal insufficiency" or "relative adrenal insufficiency." There is currently no consensus on the diagnostic criteria for this entity. A detailed discussion of this issue is found separately. (See "Corticosteroid therapy in septic shock".)

                             

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Literature review current through: Oct 2014. | This topic last updated: Feb 1, 2013.
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