What are the symptoms of adrenal insufficiency?

Symptoms of Adrenal Insufficiency

The diagnosis of primary adrenal insufficiency should be considered in all patients presenting with unexplained collapse, hypotension, vomiting or diarrhea, with hyperpigmentation, hyponatremia, hyperkalemia, acidosis, and hypoglycemia increasing clinical suspicion. 1

Common Clinical Manifestations

• Fatigue and weakness: Profound fatigue is a hallmark symptom, present in 50-95% of patients with adrenal insufficiency 2
• Gastrointestinal symptoms: Nausea, vomiting (20-62%), anorexia, and weight loss (43-73%) are common presentations 2, 3
• Postural hypotension: Often leads to dizziness, syncope, or unexplained collapse 4, 1
• Hyperpigmentation: Particularly in sun-exposed areas, skin creases, and mucous membranes (specific to primary adrenal insufficiency) 1
• Salt craving: Patients with primary adrenal insufficiency often crave salty foods due to mineralocorticoid deficiency 4

Laboratory Abnormalities

• Electrolyte disturbances: Hyponatremia and hyperkalemia are common in primary adrenal insufficiency 1
• Hypoglycemia: More common in children but can occur in adults, especially during stress or fasting 5, 1
• Mild hypercalcemia: Present in 10-20% of patients at diagnosis 1
• Hematologic changes: Anemia, mild eosinophilia, and lymphocytosis may be present 1
• Elevated liver enzymes: Increased transaminases can occur 1

Symptoms Based on Type of Adrenal Insufficiency

Primary Adrenal Insufficiency (Addison's Disease)

• Skin hyperpigmentation: Due to increased ACTH levels 1, 4
• Salt craving: Due to aldosterone deficiency 1, 4
• Hyperkalemia: Due to mineralocorticoid deficiency 1
• Low serum cortisol with elevated ACTH: Diagnostic laboratory finding 1

Secondary Adrenal Insufficiency

• Absence of hyperpigmentation: Due to low ACTH levels 6
• Normal potassium levels: Aldosterone production is relatively preserved 6
• Possible other pituitary hormone deficiencies: May present with symptoms of hypothyroidism or hypogonadism 1

Symptoms During Adrenal Crisis

Adrenal crisis is a life-threatening emergency requiring immediate treatment:

• Severe hypotension or shock: Not responsive to fluid resuscitation 1
• Altered mental status: Including confusion, loss of consciousness, and coma 1
• Severe abdominal pain: Often mimicking an acute abdomen 3
• Fever: May be present, especially if crisis is triggered by infection 1
• Severe electrolyte abnormalities: Profound hyponatremia and hyperkalemia 1

Common Pitfalls in Diagnosis

• Non-specific initial presentation: Symptoms often mimic more common conditions, leading to delayed diagnosis 3, 4
• Failure to recognize adrenal crisis: Treatment should never be delayed for diagnostic procedures in suspected acute adrenal insufficiency 1
• Confounding factors: Exogenous steroid use (oral prednisolone, dexamethasone) and inhaled steroids (fluticasone) may confound interpretation of low serum cortisol levels 1
• Thyroid function abnormalities: TSH levels are usually in the range of 4-10 IU/L in patients with primary adrenal insufficiency due to lack of inhibitory effect of cortisol on TSH production 1

Prevention and Management

• Patient education: All patients with adrenal insufficiency should receive sufficient education to manage daily medications and situations of minor to moderate concurrent illnesses 1, 4
• Identification: Patients should wear medical alert identification and carry a steroid alert card 1
• Emergency supplies: Patients should have supplies to allow self-injection of parenteral hydrocortisone 1, 4
• Dose adjustments: Patients must know how to increase medication during intercurrent illness, medical procedures, and profound stress 4

Early recognition of symptoms and prompt treatment are essential to prevent adrenal crisis, which occurs in approximately 50% of patients with adrenal insufficiency after diagnosis 4.