Diagnosis and differential diagnosis of chronic adrenal insufficiency
Endocrinology / / May 10, 2016
diagnosis of chronic adrenal insufficiency mainly based on clinical data: asthenia, pigmentation, body weight fall, hypotension, gastrointestinal manifestations, as anorexia, nausea, vomiting, diarrhea.
However, sometimes there are patients who have the most characteristic symptoms of the disease are expressed or very weak or absent.The greatest difficulty for the diagnosis arise when patients with chronic adrenal insufficiency no pigmentation, although such cases are extremely rare;pigmentation often still happens, but sometimes it is mild and atypical.Difficulty in diagnosis are also forms of the disease, in which blood pressure is at normal levels, which is usually observed in the presence of previous hypertension.In such cases are often indicate high blood pressure and changes in the past fundus.Similar erased, clinical form of the disease is not clear-cut need for further diagnosis of a special survey, t. E. The use of various tests to determine the functional state of the adrenal cortex.
usually in patients with chronic insufficiency of the adrenal cortex level 17 glucocorticoids in the blood and release of glucocorticoids 17 and 17-keto steroids in urine decreased.When samples with the introduction of ACTH, these figures do not rise.When Thorne eosinophilic sample number of eosinophils in the blood after administration of ACTH usually not reduced or is reduced by less than 50%.In patients with chronic insufficiency of the adrenal cortex samples with the introduction of ACTH can cause acute adrenal insufficiency.Therefore, these studies should be carried out only in a hospital, and in the presence of overt adrenal insufficiency - against the backdrop of substitution therapy with corticosteroids.Samples of food restriction sodium chloride, potassium load, determining the ratio of potassium and sodium in the blood plasma and saliva can detect insufficient adrenal mineralocorticoid production.Samples with water load set enable reduction in glomerular filtration rate due to lack of cortisol.
To clarify the etiology of the disease, in particular for the diagnosis of tuberculous lesions of the adrenal glands, can be applied with caution tuberculin test.In favor of tuberculous etiology of chronic adrenal insufficiency also say the presence of fever, accelerated erythrocyte sedimentation rate, the lack of effect of substitution therapy.Careful screening for tuberculosis changes in the lungs, bones, organs of the urogenital system.
However, the presence of tuberculosis infection prevents with certainty assume that chronic insufficiency of the adrenal cortex is the result of adrenal tuberculosis.On the other hand, the absence of tuberculous lesions of the adrenal glands is not rule out tuberculous nature of chronic adrenal insufficiency.Detection petrifikatov at x-ray region of the adrenal glands favors tuberculous disease etiology, but sometimes there are petrifikaty nontuberculous nature, so this feature is not pathognomonic.
differential diagnosis of primary chronic adrenal insufficiency should be carried out with adrenal insufficiency of different origin, as well as with a number of diseases associated with skin pigmentation (hemochromatosis, toxic goiter, some deficiency diseases and intoxications, scleroderma, etc.) Or adynamia and weight loss (chronicinfections, intoxications, neurasthenia, etc.).
differential diagnosis primary chronic adrenal insufficiency and decrease adrenal function associated with a decrease in production of ACTH with hypopituitarism, based on the fact that when hypopituitarism usually no pigmentation of the skin and mucous membranes and are symptoms of decreased function of the thyroid and gonads.When samples with the introduction of ACTH in patients with hypopituitarism, unlike patients with primary chronic adrenocortical insufficiency, usually increases the content of 17-hydroxycorticosteroids, and the number of eosinophils in the blood is reduced, increasing the allocation of 17-and 17-hydroxycorticosteroids ketosteroids urine.However, some patients with prolonged duration of hypopituitarism adrenocortical disease may lose the ability to respond to stimulation of adrenocorticotropic hormone and ACTH when administered with them, as well as in patients with primary chronic adrenocortical insufficiency, there is no increase production of corticosteroids.
In assessing the pigmentation of the skin as an important diagnostic sign of chronic primary adrenal insufficiency should be considered racial characteristics: a number of ethnic groups living in the south, along with the pigmentation of the skin, pigmentation is often of the mouth and genitals.
The cause of pigmentation can be tan.Sometimes, however, in patients with chronic insufficiency of the adrenal cortex pigmentation of the skin after sun exposure for the first time revealed.
In hemochromatosis, along with the deposition of iron-containing pigment in the skin - and hemosiderin pigment containing no iron - gemofustsina, may increase the amount of melanin and skin color can be very similar to the pigmentation in chronic adrenal insufficiency.Differential diagnosis is based on the presence of hemochromatosis patients with liver enlargement and violation of its functions, as well as the presence of diabetes.In difficult cases the diagnosis can help a skin biopsy or (preferably) of the liver, or bone marrow, which allows to identify deposits of iron-containing pigment.In some cases, hemochromatosis occurs adrenocortical insufficiency due to the deposition of iron-containing pigment in the adrenal cortex.
When toxic goiter, along with adynamia and weight loss, sometimes significant skin pigmentation.Differential diagnosis is performed based on the presence in patients with toxic goiter other characteristic clinical and laboratory signs of disease.
In patients with scleroderma, along with skin pigmentation due to melanin deposition, there is a characteristic thickening and thickening of the skin which is absent in patients with chronic adrenal insufficiency.
When pellagra, skin pigmentation except on the exposed parts of the body are dermatitis phenomenon;differential diagnosis is facilitated by the presence of pellagra with characteristic clinical manifestations - diarrhea, mental disturbances.
origin of pigmentation of the skin and especially the mucous membrane of the oral cavity with lead poisoning, bismuth, silver, arsenic can usually be set on the basis of history.
Diagnostic difficulties may arise in the pigmentation difference in patients with chronic insufficiency of the adrenal cortex, and acanthosis nigricans.In the initial stages of acanthosis nigricans no pappilomatoznye hyperkeratosis and skin growths that are typical of this disease, there is only skin pigmentation.The differential diagnosis in these cases is based on the absence of acanthosis nigricans with other clinical and laboratory signs of chronic adrenal insufficiency.
skin pigmentation may occur in chronic gastrointestinal and renal diseases.
In rare cases, it is necessary to differentiate chronic adrenal insufficiency with jade with the loss of sodium in which the kidneys no reaction to the mineralocorticoid effects observed weight loss, vomiting, hypotension, increased excretion of sodium in urine.In this disease, in contrast to chronic adrenocortical insufficiency, lowered concentration ability of the kidneys, urinary sodium excretion is not reduced following administration deoxycorticosterone.
In some patients, the assumption of chronic adrenal insufficiency occurs due to the presence they adinamii, anorexia, weight loss, hypotension.Such conditions can occur in neurasthenia, chronic infectious diseases, intoxications.Lack of pigmentation in these patients, as well as special studies of the functional state of the adrenal cortex allow to specify the diagnosis.
- Physiology of the adrenal cortex
- Chronic adrenal insufficiency.Addison's disease
- Pregnancy in patients with chronic insufficiency of the adrenal cortex
- blood supply and innervation of the adrenal
- Clinical evaluation of laboratory studies of the functional state of the adrenal cortex
- Determination of corticosteroids and their metabolites in urine
- Diagnosis and differential diagnosis of chronic adrenal insufficiency
- Biological effectsadrenocortical hormones.The biological effect of glucocorticoid
- morphology of adrenal
- Additional adrenal
- biosynthesis and metabolism cortex hormones adrenal
- Biological effects of C19-steroids
flow forecast, and the ability to work in chronic adrenal insufficiency
conditions depend on the nature of the pathological process in the adrenal glands.Tuberculosis their defeat in the absence of anti-TB therapy and hormone replacement therapy may lead to the death of patients with acute adrenal insufficiency, and in the coming months or years after the onset of the disease.In primary adrenal cortical atrophy progression of the disease usually occurs slowly.
most dangerous conditions, threatening the life of patients who are crises of adrenal insufficiency and severe hypoglycemia.
With proper replacement therapy with corticosteroids and - in the case of tuberculous etiology of the disease - vigorous TB treatment - patients live and to some extent, retain the ability to work for many years.
There are indications that in chronic adrenal insufficiency etiology of tuberculosis antibiotic therapy can sometimes lead to recovery.
Employability of patients with chronic adrenal insufficiency is always limited.Even when properly adjusted replacement therapy, physical and mental stress can cause acute crisis of adrenal insufficiency.Therefore, patients should be exempt from work associated with high physical activity, occupational hazards or mental strain.Depending on the profession and the severity of the disease, patients should be recognized disability group II or III.