Adrenal insufficiency: Pathology review

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Adrenal insufficiency: Pathology review

Endocrine system


Adrenal insufficiency: Pathology review

USMLE® Step 1 questions

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A 62-year-old male is evaluated post-operatively after a transsphenoidal pituitary tumor resection two days ago. He appears groggy and is unable to provide any clinical history. Past medical history is notable for Cushing disease, for which he underwent resection of the aforementioned pituitary tumor. The surgery was uncomplicated, and he is not on any medications. Temperature is 37.0°C (98.6°F), pulse is 101/min, respirations are 14/min, blood pressure is 110/60mmHg, and oxygen saturation is 97% on room air. Physical examination is notable for truncal obesity and striae. Initial laboratory findings are demonstrated below:

Which of the following laboratory findings is most representative of this patient’s clinical presentation?


While doing your rounds, you see two individuals. First is Mike, a 50-year-old immigrant from Canada who comes in with a 5-month history of progressive fatigue, weight loss, and muscle pain. Personal history is unremarkable but there’s a family history of autoimmune disease. Examination reveals hypotension, and diffuse skin hyperpigmentation most pronounced around the oral mucosa, palmar creases, and knuckles.

Then you see Teresa, a 25-year-old who presents acute vomiting, abdominal pain, and fever. She was accompanied by her mother, who mentions Teresa recently underwent transsphenoidal resection of a pituitary tumor. Examination reveals severe hypotension and altered mental status.

Morning cortisol serum measurements showed decreased levels of serum cortisol in both individuals. Both people have adrenal insufficiency although their symptoms are very different.

Now, adrenal insufficiency is a condition where the adrenal glands don’t produce enough adrenal hormones, particularly cortisol and, sometimes, aldosterone. There are actually three types of adrenal insufficiency. First, primary adrenal insufficiency is when there’s a problem with the adrenal glands themselves. As a result, both cortisol and aldosterone production is deficient. It can be acute, usually due to a massive adrenal hemorrhage, or chronic, in which case it is called Addison disease. Now, a high yield concept to remember is that the most common cause for Addison in high income countries is autoimmune mediated damage to the adrenal glands. In the rest of the world, the most common cause is infection, especially from tuberculosis, but it can also be due to HIV or disseminated fungal infections. Finally, bilateral adrenal metastases of cancer from somewhere else in the body,can also cause chronic adrenal insufficiency.


Adrenal insufficiency occurs when the adrenal glands do not produce sufficient amounts of hormones. The most common type is hypoadrenalism, which refers to insufficient production of cortisol. This can lead to some symptoms and health problems, including fatigue, weakness, weight loss, and abdominal pain. In severe cases, it can even be life-threatening.

Adrenal insufficiency is divided into two types: primary and secondary. Primary adrenal insufficiency is due to a problem with the adrenal gland itself, while secondary adrenal insufficiency is due to a problem with the pituitary gland. The pituitary gland controls the production of cortisol by the adrenal gland.


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  8. "Body Water Homeostasis: Clinical Disorders of Urinary Dilution and Concentration" Journal of the American Society of Nephrology (2006)

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