From the Guidelines
Hypocortisolism is characterized by non-specific symptoms, but common Historical Present Illness (HPI) findings include unexplained collapse, hypotension, vomiting, diarrhea, hyperpigmentation, and hypoglycemia.
Key HPI Findings
- Unexplained collapse or hypotension
- Vomiting or diarrhea
- Hyperpigmentation
- Hyponatraemia and hyperkalaemia, although these are not reliable markers for diagnosis as they may not be present in all cases 1
- Hypoglycemia, particularly in children
- Anaemia, mild eosinophilia, lymphocytosis, and increased liver transaminases may also be present 1
Laboratory Findings
- Low serum cortisol levels, often with inappropriately low levels for the disease state 1
- Elevated plasma ACTH levels 1
- Increased plasma renin activity (PRA) and low serum aldosterone and dehydroepiandrosterone sulphate (DHEAS) levels 1
- TSH levels may be elevated due to the lack of inhibitory effect of cortisol on TSH production 1
Clinical Suspicion
HPI findings such as unexplained collapse, hypotension, vomiting, or diarrhea, particularly in combination with hyperpigmentation, hyponatraemia, hyperkalaemia, acidosis, and hypoglycaemia, should raise clinical suspicion of hypocortisolism, also known as primary adrenal insufficiency (PAI) 1.
From the Research
HPI Findings for Hypocortisolism
- The study 2 reports a case of a patient with very low plasma cortisol levels without clinical manifestations of hypocortisolism, suggesting the presence of a receptor with increased sensitivity to cortisol.
- The HPI findings for hypocortisolism are not directly addressed in the studies 3, 4, 5, and 6, which focus on digital tools for obtaining the HPI, the logic of diagnosis, the therapeutic potential of the HPI, and reorganizing the HPI to improve diagnostic reasoning skills, respectively.
- However, the study 2 provides insight into the potential HPI findings for hypocortisolism, including:
- Low plasma levels of cortisol
- Absence of clinical manifestations of cortisol deficiency
- Possible altered cortisol binding capacity (CBG)
- Presence of a receptor with increased sensitivity to cortisol or another molecule that can be recognized as glucocorticoid by the cortisol receptor
Clinical Implications
- The HPI findings for hypocortisolism may vary depending on the underlying cause of the condition, such as primary or secondary adrenal hypofunction.
- Clinicians should consider the potential for altered CBG or increased sensitivity to cortisol when evaluating patients with low plasma cortisol levels.
- Further research is needed to fully understand the HPI findings for hypocortisolism and to develop effective diagnostic and therapeutic strategies for this condition.