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A42-year-old woman comes to the emergency department due to 2 syncopal episodes in

the last 3 days. The patient'was well until approximately a month ago when she began to
feel increasingly fatigued and weak. For the past 2 weeks, she has had anorexia,
nausea, and abdominal pain. The patient's medical history is unremarkable, and she
takes no medications. She drinks wine only on social occasions, and does not use
tobacco or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 86/52 mm Hg,
pulse is 90/min, and respirations are 18/min. Cardiopulmonary examination is normal.
The abdomen is mildly tender with otherwise normal findings. The skin shows
hyperpigmentation in the palmar creases. Which of the following additional findings is
most likely present in this patient?

o A Hyperglycemia
o B. Hyperkalemia
o C. Hypernatremia
o D. Hypocalcemia
0 E. Hypochloremia

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Item: ~?Mark <? C> 6f ~ ~ , ~
Q. ld : 4420 Prev1ous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 42-year-old woman comes to the emergency department due to 2 syncopal episodes in

the last 3 days. The patient was well until approximately a month ago when she began to
feel increasingly fatigued and weak. For the past 2 weeks, she has had anorexia,
nausea. and abdominal pain. The patient's medical history is unremarkable, and she
takes no medications. She drinks wine only on social occasions, and does not use
topacco or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 86/52 mm Hg,
pulse is 90/min, and respirations are 18/min. Cardiopulmonary examination is normal.
The abdomen is mildly tender with otherwise normal findings. The skin shows
hyperpigmentation in the palmar creases. Which of the following additional findings is
most likely present in this patient?

A Hyperglycemia [13%]
B. Hyperkalemia [71%]
C. Hypernatremia [8%)
D. Hypocalcemia [4%)
E. Hypochloremia [4%]

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Explanation: User

Chronic primary adrenal insufficiency

• Autoimmune
• Infections (eg, tuberculosis, HIV, disseminated fungal)
Etiology
• Hemorrhagic infarction
• Metastatic

• Fatigue, weakness, anorexia/weight loss, salt craving

• Gastrointestinal symptoms
• Postural hypotension
Clinical
features • Hyperpigmentation or vitiligo
• Hyponatremia, hyperkalemia
• May lead to acute adrenal crisis (abdominal pain,
shock, fever, altered mental status)
Item: ~?Mark <? C> 6f ~ ~ , ~
Q. ld : 4420 Prev1ous Next Lab Values Notes Calculator Reverse Color Text Zoom

Chronic primary adrenal insufficiency

• Autoimmune
• Infections (eg, tuberculosis, HIV, disseminated fungal)
Etiology
• Hemorrhagic infarction
• Metastatic

• Fatigue, weakness, anorexia/weight loss, salt craving

• Gastrointestinal symptoms
• Postural hypotension
Clinical
features • Hyperpigmentation or vitiligo
• Hyponatremia, hyperkalemia
• May lead to acute adrenal crisis (abdominal paih,
shock, fever, altered mental status)

• ACTH, serum cortisol, and high-dose (250 ~g) ACTH

stimulation test
Diagnosis o Primary adrenal insufficiency: low cortisol, high ACTH
o Secondary/tertiary adrenal insufficiency: low cortisol,
low ACTH
@UWorld

This patient has typical features of primary adrenal insufficiency (PAl), also known as
Addison disease. The initial symptoms of PAl often are nonspecific and can include
fatigue, malaise, weakness, and weight loss. Gastrointestinal symptoms (eg,
nausea, abdominal pain, diarrhea) occur in up to 90% of patients. Aldosterone deficiency
causes volume depletion and can manifest as hypotension, postural dizziness, or
syncope. Skin signs can include generalized or patchy hyperpigmentation (due to
cosecretion of melanocyte-stimulating hormone with ACTH) and vitiligo (due to
autoimmune destruction of melanocytes).

Hyponatremia is the most common electrolyte abnormality in PAl, affecting up to 90% of

patients (Choice C). In PAl, loss of mineralocorticoid secretion leads to urinary loss of
sodium, volume depletion, and a compensatory increase in the release of antidiuretic
hormone (ADH). In addition, cortisol deficiency triggers increased secretion of
corticotropin-releasing hormon.e , which directly stimulates ADH release. The resulting
retention of free water leads to dilutional hyponatremia. Conversely, aldosterone
deficiency causes hyperkalemia in a majority of patients, sometimes accompanied by a
 o Secondary/tertiary adrenal insufficiency: low cortisol,
low ACTH
@UWortd

This patient has typical features of primary adrenal insufficiency (PAl), also known as
Addison disease. The initial symptoms of PAl often are nonspecific and can include
fatigue, malaise, weakness, and weight loss. Gastrointestinal symptoms (eg,
nausea, abdominal pain, diarrhea) occur in up to 90% of patients. Aldosterone deficiency
causes volume depletion and can manifest as hypotension, postural dizziness, or
syncope. Skin signs can include generalized or patchy hyperpigmentation (due to
cosecretion of melanocyte-stimulating hormone with ACTH) and vitiligo (due to
autoimmune destruction of melanocytes).
Hyponatremia is the most common electrolyte abnormality in PAl, affecting up to 90% of
patients (Choice C). In PAl, loss of mineralocorticoid secretion leads to urinary loss of
sodium, volume depletion, and a compensatory increase in the release of antidiuretic
hormone (ADH). In addition, cortisol deficiency triggers increased secretion of
corticotropin-releasing hormone, which directly stimulates ADH release. The resulting
retention of free water leads to dilutional hyponatremia. Conversely, aldosterone
deficiency causes hyperkalemia in a majority of patients, sometimes accompanied by a
mild hyperchloremic acidosis (Choice E).

(Choice A) Hypoglycemia is a potential complication of PAl and can be triggered by

fasting, infection, or alcohol consumption. Hyperglycemia is not seen in the absence of
preexisting type 1 diabetes mellitus.
(Choice 0) PAl can cause mild hypercalcemia due to increased release of calcium from
the bones, increased proximal tubular reabsorption, and volume contraction. PAl with
concurrent hypoparathyroidism leading to hypocalcemia can be seen in the polyglandular
autoimmune syndrome type 1 but is extremely rare.
Educational objective:
Chronic adrenal insufficiency presents with weight loss, fatigue, and gastrointestinal
symptoms. Volume depletion can cause hypotension and syncope. Most patients have
hyponatremia due to renal sodium loss and increased release of antidiuretic hormone·.
Hyperkalemia is also common due to mineralocorticoid deficiency.

References:
1. Diagnosis and treatment of primary adrenal insufficiency : an endocrine
society clinical practice guideline.

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