Suprarrenal insufficiency

Suprarrenal insufficiency. The insufficiency of the adrenal glands is an endocrine disease that endangers the patient’s life, by affecting his ability to respond to stress . It can present a slow and progressive form (chronic adrenal insufficiency) or an acute form, regardless of the existence or not of previous symptoms or signs of the disease (acute adrenal insufficiency).

In general, the clinical picture only occurs when more than 90% of the glandular tissue has been destroyed. Its frequency in the population is variable, according to its cause. The chronic form has an incidence around 0.04% of the general population.

Summary

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  • 1 Causal Classification
  • 2 Clinical Picture
  • 3 Complementary Exams
  • 4 Treatment
    • 1 Principles of treatment
  • 5 Source

Causal Classification

Primary

  • Bilateral adrenal tuberculosis.
  • Primary atrophy.
  • Venous thrombosis and arterial embolism.
  • Neoplasia, metastasis and mycosis fungoides.
  • Syphilis, brucellosis, malaria.
  • Mycosis, coccidiodomicosis, histoplasmosis, torulosis, moniliasis, and blastomycosis.
  • Reticuloendothelioma, Hodgkin’s disease, and leukemia.
  • Infections: meningococcal, staphylococcal, diphtheriaand Typhoid Fever .
  • Post-surgical adrenal enzyme deficiency

(bilateral adrenalectomy).

– Autoimmune diseases .

High school

– Global or partial or selective hypopituitarism of ACTH.

– Limited reserve of ACTH (adrenocorticotropic hormone).

Others

–Long treatment with glucocorticoids.

– Hyperthyroidism .

– Malabsorption syndrome .

Clinical Picture

  • Most striking symptoms:asthenia, easy fatigue, progressive weight loss, anorexia , diarrhea , abdominal pain , personality change, decreased libido, hunger for salt, symptoms of hypoglycemia and orthostatic syncope .
  • Signs: hypotensionmaintained and orthostatic, dark pigmentation mucocutaneous (primary adrenal insufficiency), decreased axillary pubic hair, calcification of the cartilage of the ear and decreased muscle strength.

Complementary Exams

Non-specific

  1. a) Blood count.

– Hypochromic or normochromic and normocytic anemia.

– Leukopenia and neutropenia, without proportional elevation in the presence of infections.

– Lymphocytosis and eosinophilia.

  1. b) Elevated erythrosedimentation, with greater intensity in adrenal tuberculosis.
  2. c) Ionogram (mainly affected in advanced cases.

– Decreased sodium (<130 mEq / L).

– Increased potassium (> 5 mEq / L).

– Sodium-potassium index less than 30 (normal, 32.

  1. d) Gasometry: moderate metabolic acidosis.
  2. e) Decreased cholesterol.
  3. f) Proteinelectrophoresis : increased gamma globulin.
  4. g) x- ray: search for tubercular lesions, fungal or neoplastic.
  5. h) Simple abdominal radiography: calcification of the adrenal glands in tuberculosis and some mycoses.

Specific

  1. a) Plasma cortisol.
  2. b) 17-OHCS in 24-hour urine.
  3. c) Stimulation test with ACTH.
  4. d) Water overload test.

Treatment

Principles of treatment

  1. In case of diagnostic doubts, treatment (therapeutic diagnosis) should be administered and the repetition of the study should be subsequently evaluated, if the patient responds favorably.
  2. Never stop treatment if you cannot prove that the positive diagnosis was wrong.
  3. Base treatment on the administration of glucocorticoid hormones.
  4. Be alert to the possibility of an acute adrenal crisis.

Medications and measures to be applied

  1. Diet rich in sodium: 5 of 15 g of extra common salt in food.
  2. Glucocorticoid therapy: in order of preference, the following will be administered:
  3. a) Cortisone acetate: 25 to 37.5 mg / d as a maintenance dose orally.
  4. b) Hydrocortisone: 20 to 30 mg / d orally. Failing this, equivalent doses of the available glucocorticoid will be used. If prednisone(5 to 7.5 mg / d) is used, a mineralocorticoid drug will be associated. In any case, it will be replaced by cortisone as soon as possible; preferably 2/3 of the total glucocorticoid dose will be administered in the morning (8:00 am) and 1/3 in the afternoon (6:00 pm – 8:00 pm).
  5. Mineralocorticoid therapy.
  6. a) Medicine of choice: 9-alpha-fluorhydrocortisone: 0.05 to 0.2 mg / d orally (0.1 mg tablets) b) Failing this: deoxycorticosterone acetate (DO-CA): 5 mg IM, 2-3 times / week, depending on individual needs.
  7. c) Treatment with mineralocorticoids will be indicated mainly in primary insufficiencies, as well as in secondary adrenal insufficiency if symptoms or signs of hypotension are maintained, despite glucocorticoids.
  8. d) It is an individually manipulated medicine: its use should be avoided if there is high blood pressureor heart failure. The appearance of edema should also be monitored.
  9. Treatment of underlying disease.

 

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