Secondary adrenal insufficiency
Tumors of the pituitary or surrounding structures are the most common cause of secondary adrenal insufficiency. This includes adenomas, cysts, craniopharyngiomas, and other tumors. Traumatic brain injuries, especially those that result in trauma to the pituitary stalk, should also be considered.
Secondary adrenal insufficiency can cause hypotension, hypoglycemia, fatigue, and weight loss. Due to pituitary or hypothalamic dysfunction, other endocrine systems may also manifest deficiency. Visual impairment can occur if a tumor compresses the nearby optic chiasm.
Adrenal crisis is a potentially life-threatening complication. It is characterized by severe hypotension, vomiting, dehydration, abnormal electrolytes, and hypoglycemia. This requires immediate evaluation and treatment with intravenous (IV) fluid boluses and hormone replacement.
E27.40 – Unspecified adrenocortical insufficiency
16685009 – Hypocortisolism secondary to another disorder
- Adrenal crisis – hypotension, mental status changes, vomiting, hypoglycemia, hyponatremia, hyperkalemia, hypercalcemia
- Addison disease – autoimmune disorder, associated with elevated ACTH
- Sarcoidosis – caused by granuloma in adrenal glands
- Tuberculosis – most common cause of primary adrenal insufficiency worldwide
- Opportunistic infections – disseminated fungal infections can cause primary adrenal insufficiency, especially in the setting of human immunodeficiency virus (HIV) infection
- Waterhouse-Friderichsen syndrome – associated with bacterial infection, especially Neisseria meningitidis
- Adrenal hemorrhage
- Postpartum hypopituitarism (Sheehan syndrome) – hypopituitarism following severe postpartum hemorrhage
- Malignancy (particularly metastasis to adrenal glands, primary adrenal tumors)
- Shock (septic, hypovolemic, cardiogenic, etc)
- Congenital adrenal hyperplasia – often associated with salt wasting and virilization
- Trauma – especially traumatic brain injury
- Genetic conditions – mutations in genes related to pituitary development (includes: HESX homeobox 1, orthodentical homeobox 2, LIM homeobox 4, SRY, congenital proopiomelanocortin deficiency, Prader-Willi syndrome)
- Adrenoleukodystrophy – X-linked peroxisomal disease
- Amyloidosis (AA amyloidosis, AL amyloidosis)
- Iatrogenic – medications include chlorpromazine, imipramine, etomidate, ketoconazole, fluconazole, suramin, phenytoin, barbiturates, mifepristone, rifampin, and opiates
- Chronic corticosteroid use – common cause of tertiary adrenal insufficiency, suppresses hypothalamic-pituitary-adrenal axis
- Hypoglycemia – exogenous insulin or oral antihyperglycemic drugs, malnourishment, or alcohol intoxication