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Adrenal Failure: An Evidence-Based Diagnostic Approach

The diagnosis of adrenal insufficiency (AI) requires a high index of suspicion, detailed clinical assessment including detailed drug history, and appropriate laboratory evaluation. The clinical characteristics of adrenal insufficiency vary according to the cause, and the presentation may be myriad,...

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Autores principales: Shaikh, Salomi, Nagendra, Lakshmi, Shaikh, Shehla, Pappachan, Joseph M.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: MDPI 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10217071/
https://www.ncbi.nlm.nih.gov/pubmed/37238296
http://dx.doi.org/10.3390/diagnostics13101812
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author Shaikh, Salomi
Nagendra, Lakshmi
Shaikh, Shehla
Pappachan, Joseph M.
author_facet Shaikh, Salomi
Nagendra, Lakshmi
Shaikh, Shehla
Pappachan, Joseph M.
author_sort Shaikh, Salomi
collection PubMed
description The diagnosis of adrenal insufficiency (AI) requires a high index of suspicion, detailed clinical assessment including detailed drug history, and appropriate laboratory evaluation. The clinical characteristics of adrenal insufficiency vary according to the cause, and the presentation may be myriad, e.g. insidious onset to a catastrophic adrenal crisis presenting with circulatory shock and coma. Secondary adrenal insufficiency (SAI) often presents with only glucocorticoid deficiency because aldosterone production, which is controlled by the renin angiotensin system, is usually intact, and rarely presents with an adrenal crisis. Measurements of the basal serum cortisol at 8 am (<140 nmol/L or 5 mcg/dL) coupled with adrenocorticotrophin (ACTH) remain the initial tests of choice. The cosyntropin stimulation (short synacthen) test is used for the confirmation of the diagnosis. Newer highly specific cortisol assays have reduced the cut-off points for cortisol in the diagnosis of AI. The salivary cortisol test is increasingly being used in conditions associated with abnormal cortisol binding globulin (CBG) levels such as pregnancy. Children and infants require lower doses of cosyntropin for testing. 21-hydoxylase antibodies are routinely evaluated to rule out autoimmunity, the absence of which would require secondary causes of adrenal insufficiency to be ruled out. Testing the hypothalamic–pituitary–adrenal (HPA) axis, imaging, and ruling out systemic causes are necessary for the diagnosis of AI. Cancer treatment with immune checkpoint inhibitors (ICI) is an emerging cause of both primary AI and SAI and requires close follow up. Several antibodies are being implicated, but more clarity is required. We update the diagnostic evaluation of AI in this evidence-based review.
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spelling pubmed-102170712023-05-27 Adrenal Failure: An Evidence-Based Diagnostic Approach Shaikh, Salomi Nagendra, Lakshmi Shaikh, Shehla Pappachan, Joseph M. Diagnostics (Basel) Review The diagnosis of adrenal insufficiency (AI) requires a high index of suspicion, detailed clinical assessment including detailed drug history, and appropriate laboratory evaluation. The clinical characteristics of adrenal insufficiency vary according to the cause, and the presentation may be myriad, e.g. insidious onset to a catastrophic adrenal crisis presenting with circulatory shock and coma. Secondary adrenal insufficiency (SAI) often presents with only glucocorticoid deficiency because aldosterone production, which is controlled by the renin angiotensin system, is usually intact, and rarely presents with an adrenal crisis. Measurements of the basal serum cortisol at 8 am (<140 nmol/L or 5 mcg/dL) coupled with adrenocorticotrophin (ACTH) remain the initial tests of choice. The cosyntropin stimulation (short synacthen) test is used for the confirmation of the diagnosis. Newer highly specific cortisol assays have reduced the cut-off points for cortisol in the diagnosis of AI. The salivary cortisol test is increasingly being used in conditions associated with abnormal cortisol binding globulin (CBG) levels such as pregnancy. Children and infants require lower doses of cosyntropin for testing. 21-hydoxylase antibodies are routinely evaluated to rule out autoimmunity, the absence of which would require secondary causes of adrenal insufficiency to be ruled out. Testing the hypothalamic–pituitary–adrenal (HPA) axis, imaging, and ruling out systemic causes are necessary for the diagnosis of AI. Cancer treatment with immune checkpoint inhibitors (ICI) is an emerging cause of both primary AI and SAI and requires close follow up. Several antibodies are being implicated, but more clarity is required. We update the diagnostic evaluation of AI in this evidence-based review. MDPI 2023-05-21 /pmc/articles/PMC10217071/ /pubmed/37238296 http://dx.doi.org/10.3390/diagnostics13101812 Text en © 2023 by the authors. https://creativecommons.org/licenses/by/4.0/Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
spellingShingle Review
Shaikh, Salomi
Nagendra, Lakshmi
Shaikh, Shehla
Pappachan, Joseph M.
Adrenal Failure: An Evidence-Based Diagnostic Approach
title Adrenal Failure: An Evidence-Based Diagnostic Approach
title_full Adrenal Failure: An Evidence-Based Diagnostic Approach
title_fullStr Adrenal Failure: An Evidence-Based Diagnostic Approach
title_full_unstemmed Adrenal Failure: An Evidence-Based Diagnostic Approach
title_short Adrenal Failure: An Evidence-Based Diagnostic Approach
title_sort adrenal failure: an evidence-based diagnostic approach
topic Review
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10217071/
https://www.ncbi.nlm.nih.gov/pubmed/37238296
http://dx.doi.org/10.3390/diagnostics13101812
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