✅The correct answer is: C.
🔺This patient has several features of chronic primary adrenal insufficiency (PAI), including weight loss, abdominal pain, and fatigue. Hyperpigmentation is a common finding and is due to cosecretion of melanocyte- stimulating hormone with ACTH (both are derived from proopiomelanocortin), which is increased in response to cortisol deficiency. In addition , loss of mineralocorticoid production can cause hypotension, hyponatremia, and hyperkalemia. Eosinophilia and hyperplasia of lymphoid tissue (eg, tonsils) are common but nonspecific findings.
⚠️Autoimmune adrenalitis is responsible for >90% of cases of PAI in developed countries. It is due to autoantibodies against adrenal enzymes that are responsible for corticosteroid synthesis. Autoimmune adrenalitis can occur as an isolated disorder or in association with other autoimmune syndromes (eg, primary hypothyroidism, vitiligo).
❎(Choice A) Bilateral adrenal hemorrhage due to sepsis (eg, Neisseria meningitidis) can lead to PAI; however, this is less common, and the onset of clinical features is typically acute and dramatic.
❎(Choice B) Hyperfunctioning adrenal tumors are a potential cause of hypercortisolism, but not PAI. Bilateral adrenal metastasis can cause PAI but this is a rare occurrence.
❎(Choice D) Exogenous glucocorticoids can suppress pituitary secretion of ACTH and hypothalamic production of corticotropin-releasing hormone, leading to central (secondary) adrenal insufficiency. In contrast to PAl, secretion of melanocyte-stimulating hormone is not increased so patients do not display hyperpigmentation,. Also, because mineralocorticoid production is controlled by the renin-angiotensin system, aldosterone levels are normal and hyperkalemia is not seen with central adrenal insufficiency.
❎(Choice E) PAI in HIV disease can be due to opportunistic infections (eg, cytomegalovirus, atypical mycobacteria, fungal infections) or inhibition of glucocorticoid synthesis by azole antifungal drugs. However, this patient has no apparent opportunistic infections, and her other autoimmune findings make autoimmune adrenalitis more likely.
❎(Choice F) PAI due to tuberculosis (TB) is typically seen with miliary disease and is uncommon in developed countries. It is unlikely that this patient contracted TB and so rapidly developed manifestations of TB-induced PAI following her trip to Thailand 6 months ago.
✳️Primary adrenal insufficiency:
🔺Etiology:
• Autoimmune adrenalitis (most common)
• Infection (eg, tuberculosis)
• etastatic infiltration
🔺Clinical features:
• Fatigue, weakness, anorexia/weight loss
• Nausea, vomiting, abdominal pain
• Salt craving, postural hypotension
• Hyperpigmentation
• Acute adrenal crisis: confusion, hypotension/shock
🔺 Laboratory findings:
• Hyponatremia, hyperkalemia, eosinophilia
• Low morning cortisol, high ACTH
🔺 Treatment:
• Glucocorticoids (eg, hydrocortisone, prednisone)
• Mineralocorticoids (eg, fludrocortisone)
#endocrinology
#step2
🔺This patient has several features of chronic primary adrenal insufficiency (PAI), including weight loss, abdominal pain, and fatigue. Hyperpigmentation is a common finding and is due to cosecretion of melanocyte- stimulating hormone with ACTH (both are derived from proopiomelanocortin), which is increased in response to cortisol deficiency. In addition , loss of mineralocorticoid production can cause hypotension, hyponatremia, and hyperkalemia. Eosinophilia and hyperplasia of lymphoid tissue (eg, tonsils) are common but nonspecific findings.
⚠️Autoimmune adrenalitis is responsible for >90% of cases of PAI in developed countries. It is due to autoantibodies against adrenal enzymes that are responsible for corticosteroid synthesis. Autoimmune adrenalitis can occur as an isolated disorder or in association with other autoimmune syndromes (eg, primary hypothyroidism, vitiligo).
❎(Choice A) Bilateral adrenal hemorrhage due to sepsis (eg, Neisseria meningitidis) can lead to PAI; however, this is less common, and the onset of clinical features is typically acute and dramatic.
❎(Choice B) Hyperfunctioning adrenal tumors are a potential cause of hypercortisolism, but not PAI. Bilateral adrenal metastasis can cause PAI but this is a rare occurrence.
❎(Choice D) Exogenous glucocorticoids can suppress pituitary secretion of ACTH and hypothalamic production of corticotropin-releasing hormone, leading to central (secondary) adrenal insufficiency. In contrast to PAl, secretion of melanocyte-stimulating hormone is not increased so patients do not display hyperpigmentation,. Also, because mineralocorticoid production is controlled by the renin-angiotensin system, aldosterone levels are normal and hyperkalemia is not seen with central adrenal insufficiency.
❎(Choice E) PAI in HIV disease can be due to opportunistic infections (eg, cytomegalovirus, atypical mycobacteria, fungal infections) or inhibition of glucocorticoid synthesis by azole antifungal drugs. However, this patient has no apparent opportunistic infections, and her other autoimmune findings make autoimmune adrenalitis more likely.
❎(Choice F) PAI due to tuberculosis (TB) is typically seen with miliary disease and is uncommon in developed countries. It is unlikely that this patient contracted TB and so rapidly developed manifestations of TB-induced PAI following her trip to Thailand 6 months ago.
✳️Primary adrenal insufficiency:
🔺Etiology:
• Autoimmune adrenalitis (most common)
• Infection (eg, tuberculosis)
• etastatic infiltration
🔺Clinical features:
• Fatigue, weakness, anorexia/weight loss
• Nausea, vomiting, abdominal pain
• Salt craving, postural hypotension
• Hyperpigmentation
• Acute adrenal crisis: confusion, hypotension/shock
🔺 Laboratory findings:
• Hyponatremia, hyperkalemia, eosinophilia
• Low morning cortisol, high ACTH
🔺 Treatment:
• Glucocorticoids (eg, hydrocortisone, prednisone)
• Mineralocorticoids (eg, fludrocortisone)
#endocrinology
#step2