What are the clinical presentations of adrenal insufficiency?

From the Guidelines

Adrenal insufficiency presents with a constellation of symptoms resulting from inadequate cortisol production, including fatigue, weakness, weight loss, anorexia, and gastrointestinal symptoms, and requires immediate treatment when suspected to prevent adrenal crisis. The clinical presentation of adrenal insufficiency can vary, but common symptoms include:

• Fatigue, weakness, and weight loss
• Anorexia, nausea, vomiting, abdominal pain, and diarrhea
• Orthostatic hypotension due to volume depletion and loss of mineralocorticoid function
• Hyperpigmentation of skin and mucous membranes in primary adrenal insufficiency (Addison's disease) due to elevated ACTH levels
• Salt craving, hypoglycemia, myalgias, arthralgias, and psychiatric symptoms such as depression, irritability, and poor concentration
• Laboratory findings include hyponatremia, hyperkalemia, and hypoglycemia, particularly in primary adrenal insufficiency 1.

Acute adrenal crisis presents more dramatically with severe hypotension or shock, fever, altered mental status, and acute abdominal pain that can mimic an acute abdomen 2. Secondary adrenal insufficiency (pituitary origin) typically lacks hyperpigmentation and electrolyte abnormalities since aldosterone production remains intact. Diagnosis requires measurement of morning cortisol levels and ACTH stimulation testing. Treatment involves glucocorticoid replacement (hydrocortisone 15-25 mg daily in divided doses) and mineralocorticoid replacement (fludrocortisone 0.05-0.2 mg daily) for primary adrenal insufficiency, with dose adjustments during illness or stress 3. It is essential to educate patients on stress dosing for sick days, use of emergency steroid injectables, and when to seek medical attention for impending adrenal crisis 4.

From the Research

Clinical Presentation of Adrenal Insufficiency

The clinical presentation of adrenal insufficiency can vary, but common features include:

• Unintentional weight loss
• Anorexia
• Postural hypotension
• Profound fatigue
• Muscle and abdominal pain
• Hyponatraemia 5
• Skin hyperpigmentation and salt cravings in primary adrenal insufficiency 5, 6

Specific Clinical Features

Patients with primary adrenal insufficiency often develop:

• Skin hyperpigmentation 5, 6
• Salt cravings 5 In contrast, secondary or tertiary adrenal insufficiency may present with glucocorticoid deficiency only, but manifestations of the primary pathological disorder can also be present 7

Non-Specific Clinical Features

The initial presentation of adrenal insufficiency is often non-specific, making diagnosis challenging:

• Fatigue
• Weight loss
• Gastrointestinal manifestations 6
• Delayed diagnosis or misdiagnosis due to unspecific symptoms 8

Life-Threatening Situations

Adrenal insufficiency can lead to life-threatening situations, such as:

• Adrenal crisis, which requires prompt therapeutic management, including fluid resuscitation and stress dose hydrocortisone administration 9, 8
• Increased mortality in patients with primary or secondary adrenal insufficiency despite state-of-the-art steroid replacement therapy 5