Session: S32-Clinical Management of Adrenal Insufficiency: Update 2013
Room 307 (Moscone Center)
The diagnosis of primary adrenal insufficiency (PAI) is usually easy. Low morning cortisol combined with elevated ACTH confirms PAI; low aldosterone and DHEAS and elevated renin activity are typical. The main challenge is to keep vigilant to the possibility that the patient with weakness, weight loss and hypotension may suffer from PAI; look for hyperpigmentation and hyperkalemia and ask about salt craving. The dominating cause is autoimmunity, which can be verified by measurement of 21-hydroxylase antibodies. In antibody-negative PAI other causes such as tuberculosis, hemorrhages, infections, malignant infiltration, and monogenetic disorders must be sought. The diagnosis of secondary adrenal insufficiency (SAI) can be difficult and will usually require stimulation testing. Any use of exogenous glucocorticoids must be identified. If SAI is verified an MRI of the pituitary is required to search for a pituitary mass. If no tumor is present, autoimmune hypophysitis and rare genetic forms of ACTH-deficiency must be considered.
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