Adrenal insufficiency

Last revised by Ammar Ashraf on 12 Oct 2023

Adrenal insufficiency refers to inadequate secretion of corticosteroids (glucocorticoids and mineralocorticoids).

It may occur from partial or complete destruction of the adrenal cortex, in which case it is termed primary adrenal insufficiency (also known as Addison disease). Secondary adrenal insufficiency due to lack of stimulation of the gland is a more common etiology overall.

Depends on the course of the disease:

  • acute stage: the patient presents with fever, back pain, hypotension, weakness
  • chronic stage: progressive lethargy, weakness, cutaneous pigmentation, weight loss
  • chemistry: hyponatremia, hyperkalemia, azotemia, hypercalcemia, hypoglycemia
  • adrenocorticotrophic hormone (ACTH) stimulation test:
    • primary adrenal insufficiency
      • cortisol levels fail to rise after synthetic ACTH stimulation due to the destruction of the adrenal cortex
    • secondary adrenal insufficiency
      • cortisol levels rise after synthetic ACTH stimulation
      • this indicates decreased ACTH secretion due to pituitary dysfunction

The disease course may be either acute, subacute, or chronic 2:

  • acute: occurs within a few weeks to months and is caused by bilateral adrenal hemorrhage (adrenal apoplexy) or secondary to shock and sepsis or trauma (Addisonian crisis)
  • subacute disease (adrenalitis): when the disease has been present for less than two years
  • chronic: secondary to chronic autoimmune disorder or chronic granulomatous infection (tuberculosis)
    • the adrenal glands become atrophic and calcified

Adrenal insufficiency is a bilateral process that cannot be diagnosed by imaging alone. CT would be the best imaging modality for adrenal assessment but is not necessary for diagnosis.

Imaging features depend on the cause and the course of the disease either acute, subacute, or chronic:

  • acute: bilateral adrenal hematomas
  • subacute (adrenalitis): enlargement of both adrenal glands, with necrotic centers and peripheral enhancing rims
  • chronic: both adrenal glands appear small and atrophic, associated with calcifications (adrenal calcification) in granulomatous adrenalitis
  • acute: glucocorticoid therapy, volume, and electrolyte replacement 
  • chronic: glucocorticoid and mineralocorticoid replacement

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Cases and figures

  • Case 1: secondary to tuberculous infection
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  • Case 2: calcified adrenals from previous tuberculosis
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  • Case 3: antiphospholipid syndrome with adrenal insufficiency
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