Adrenal insufficiency: Clinical

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Adrenal insufficiency: Clinical

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A 76-year-old male presents to the emergency department with altered mental status. The patient was found down for an unknown period of time by neighbors. His initial blood sugar was 45 mg/dL, for which he was given dextrose prior to arrival. He is unable to provide any medical history due to his mental status. Temperature is 38.3°C (101°F), pulse is 110/min, respirations are 21/min, blood pressure is 84/62 mmHg, and oxygen saturation is 92% on room air. Physical examination is notable for a confused male in moderate respiratory distress with rales at the right lower lobe. The patient is given two liters of intravenous normal saline, acetaminophen, intravenous ceftriaxone and azithromycin, and norepinephrine without improvement in his vital signs or clinical status. A repeat blood sugar is 37 mg/dL, and initial laboratory findings are demonstrated below:

Which of the following medications is indicated for management of this patient's clinical presentation?


Adrenal insufficiency is a condition in which the adrenal glands don’t produce enough adrenal hormones - particularly cortisol, but sometimes aldosterone can be deficient as well.

Cortisol production is normally under the control of the hypothalamus and pituitary. The hypothalamus secretes corticotropin-releasing hormone, or CRH, which makes the pituitary gland secrete adrenocorticotropic hormone, or ACTH.

ACTH then stimulates the release of cortisol from the adrenal glands. Aldosterone, on the other hand, is the final product of a physiological chain called the renin-angiotensin-aldosterone system, or RAAS for short.

Renin is produced by the kidneys, so aldosterone production is actually independent of hypothalamic and pituitary stimulation. This is important, because adrenal insufficiency actually comes in three distinct flavors.

First, there’s primary adrenal insufficiency, or Addison’s disease, when there’s a problem with the adrenal glands themselves. In this case, both cortisol and aldosterone production are deficient.

The most common cause for primary adrenal insufficiency in high income countries is autoimmune destruction of the adrenal gland. Another common cause can be due to tuberculosis, HIV, or disseminated fungal infections.

Finally, bilateral adrenal metastases from cancer somewhere else in the body, like the lungs, breast, or colon, can also cause adrenal insufficiency.


Addison's disease, or adrenal insufficiency, is a rare disorder that occurs when the adrenal glands do not produce enough hormones. Adrenal insufficiency can be caused by several conditions, including autoimmune disease, infection, or failure of the adrenal glands.

Symptoms of adrenal insufficiency include fatigue, muscle weakness, weight loss, darkening of the skin (hyperpigmentation), and low blood pressure. Addison's disease is a serious condition that can be life-threatening if not treated properly.


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