ADDISON’S DISEASE

A condition where the adrenal gland produces insufficient glucocorticoid hormones (adrenal insufficiency)

Causes

  • More common: abrupt cessation of steroid treatment after long use
  • Autoimmune (self destruction of the gland)
  • TB of the adrenals, HIV/AIDS
  • Surgical adrenal removal, cancer affecting adrenal glands, bleeding into the adrenals, necrosis of the adrenals

Clinical features

Acute

  • Weakness and fatigability (getting tired easily)
  • Shock, very low BP
  • Hypoglycaemic attacks
  • Mental changes, e.g., irritability and restlessness until coma
  • Fever, hyponatremia (low Na), hyperkalemia (high K), acidosis

Chronic

  • As above plus weight loss, hair loss
  • Darkening of the skin and mouth
  • Menstrual disturbance and infertility
  • Symptoms are worse in situations of stress (e.g. infections)

Differential diagnosis

  • HIV/AIDS, TB, cancer
  • Depression
  • Diabetes mellitus
  • Hypothyroidism

Investigations

  • Drug history
  • Refer at higher level for hormone tests if no clear history of abrupt withdrawal of steroid treatment

Management

Acute crisis

  • Hydrocortisone 100 mg IV 6 hourly until stable, then switch to oral
    Child 0-3 years: 25 mg
    Child 3-12 years: 50 mg
  • IV fluids and dextrose to maintain normal volume and blood sugar
  • Treat complications/concomitant illnesses (e.g. infections)

Chronic case

  • If history of abrupt steroid cessation, restart prednisolone treatment, and slowly decrease it
    by 2.5-5 mg per week
  • Replacement treatment with prednisolone (5-7.5 mg/day)
    Child: 1-5 mg/day
  • Use doses as in acute regimens in case of stress (e.g., surgery, disease, labour)

Prevention

  • Avoid self medication with steroids (prednisolone, dexamethasone)
  • Decrease steroids gradually if used for treatment durations longer than 2 weeks (see above)