1. + This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. + Ali Ibrahim Alsagheir Addison Disease

3. + Index : Introduction ADDISON disease Definition Pathophysiology Clinical manifestation Diagnosis RX Addison crisis

4. + Causes of adrenal insufficiency : primary adrenal insufficiency ((ADDISON’sDISEASE)): The problem due to a disorder of the adrenal glands themselves. secondary adrenal insufficiency: Inadequate secretion of ACTH by the pituitary gland.

5. + Diff. between primary & secondary: Primary adrenal ins.Secondary ( ↑ ACTH)( ↓ ACTH) Glucocorticoid insufficiency Mineralocorticoid insufficiencynormal

6. + is a rare endocrine disorder, first described by British physician Thomas Addison. 1 in 100,000 people. It occurs in all age groups and affects men and women equally. > 90% of adrenal tissue is destroyed.

7. +

8. + Etiology of Primary adrenal insufficiency : Autoimmune TB HIV/AIDS Metastatic cancer Bilateral Adrenalectomy Rare: amyloidosis, inta-adrenal heamorrhage, lymphoma

9. + Clinical manifestations of chronic adrenal insufficiency symptomsFrequency Weakness, tiredness, fatigue100 Anorexia100 Gastrointestinal symptoms92 Postural dizziness 6 -13 Muscle or joint pains 12

10. + Clinical manifestations of chronic adrenal insufficiency SignFrequency, percent Weight loss100 Hyperpigmentation94 Hypotension (systolic BP <110 mmHg) 88-94 Vitiligo20

11. +

12. + Clinical manifestations of chronic adrenal insufficiency Laboratory abnormalityFrequency Hyponatremia88 Hyperkalemia64 Hypercalcemia6 Azotemia55 Anemia40 Eosinophilia17

13. + Diagnosis : Random Plasma Cortisol: usually low Acth Stimulation Test (short Synacthen test): 250 μ g ACTH 1-24 (Synacthen) by i.m. injection at any time of day Blood samples: 0 and 30 minutes for plasma cortisol Normal subjects plasma cortisol> 460 nmol/l Inadrenal insufficiencycortisol level fail to increase. Then see ACTH: high ((primary)), low ((secondary)) Plasma renin and aldosterone

14. + Treatment: Glucocorticoid replacement : Cortisol (hydrocortisone) is the drug of choice. 15 -25 mg/day in 2-3 divided does 2/3 in morning, 1/3 afternoon Mineralocorticoid replacement : Fludrocortisone 0.05 – 0.2 mg/daily Adjust both on clinical ground

15. + ADVICES: Intercurrent stress: eg. Febrile illness - *2 does of hydrocortisone Surgery: 150 -300mg parenteal hydrocortisone daily (in 3 divided doses) Gastroenteritis: Parenteral hydrocortisone Instructed in the use of IM emergency hydrocortisone. All ptn should wear a medical information bracelet.

16. + ADDISION CRISIS 45y/o, female, c/o anorexia, not feeling well, hyperpigmentation, lethargy, wt. loss for 1 year Now present to the E/R with severe diarrhea and loss of consciousness On examination: Decrease BP, dehydration, hyperpigmentation, no axillary hair Labs : Na = 124, K= 5.9, cl = 82, HCO3= 17, ph = 7.2

17. + ADDISION CRISIS It is a medical emergency. Untreated, an Addisonian crisis can be fatal. therapy should be instituted immediately upon suspicion. Precipitating factor : Infection, trauma, surgery. Or sudden withdrawal of steriods.

18. + Clinical manifestations : SHOCK ((low blood pressure, tachycardia, oliguria)) sudden penetrating pain in the legs, lower back or abdomen severe vomiting and diarrhea, resulting in dehydration loss of consciousness hypoglycemia

19. + ADDISION CRISIS Diagnosis : Serum Cortisol, confirmation by an ACTH stimulation test should be postponed until the patient has recovered. RX : IV HYDROCORTISONE SUCCINATE 100 MG/6H for 48 hour,then start oral. IV FLUID ((NORMAL SALINE AND 10% DEXTROSE )) Precipitating cause should be treated.

20. + THANK YOU,,: