Adrenal insufficiency

　　Common causes of adrenal insufficiency include adrenal tuberculosis or autoimmune adrenalitis; rare causes include deep fungal infection, immunodeficiency, viral infection, malignant tumors, extensive adrenal hemorrhage, surgical resection of the adrenal glands, leukodystrophy, and secondary adrenal insufficiency associated with POEMS disease, etc. The most common cause is long-term use of supraphysiological doses of glucocorticoids, which can also be secondary to hypothalamic-pituitary diseases such as sellar tumors, autoimmune pituitaryitis, trauma, surgical resection, postpartum massive hemorrhage leading to extensive infarction and necrosis of the pituitary, i.e., Sheehan syndrome, etc.

　　Adrenal insufficiency can trigger adrenal crisis during stress states (such as trauma, infection) or sudden discontinuation of hormone replacement therapy, which may present with nausea, vomiting, fainting, shock, and coma.

　　Adrenal insufficiency may not be noticed until many years later. Occasionally, some cases may be triggered by stress such as infection, trauma, surgery, and only discovered clinically when adrenal crisis occurs.

　　1. Hyperpigmentation

　　Primary patients have hyperpigmentation of the skin and mucous membranes, which is often diffuse, most pronounced on exposed areas, frequently rubbed areas, and at the roots of nails (toes), scars, areolas, external genitalia, perianal area, gums, oral mucosa, and conjunctiva. Some patients with vitiligo may have areas of hypopigmentation. Secondary adrenal insufficiency patients have significantly reduced MSH and ACTH levels, so there is no hyperpigmentation.

　　2. Fatigue

　　The degree of fatigue is parallel to the severity of the disease. Mild cases may only show poor endurance in labor, while severe cases may be unable to get out of bed. It is caused by electrolyte imbalance, dehydration, and disturbances in protein and sugar metabolism.

　　3. Gastrointestinal symptoms

　　Loss of appetite, nausea, vomiting, epigastric, right lower quadrant or non-localized abdominal pain, sometimes accompanied by diarrhea or constipation. A preference for high-sodium diet is common. Weight loss is often present. Gastrointestinal symptoms are more common in patients with long-standing disease and severe conditions.

　　4. Cardiovascular symptoms

　　Due to sodium deficiency, dehydration, and insufficient corticosteroids, patients often have low blood pressure (systolic and diastolic blood pressure both decrease) and orthostatic hypotension. Heart rate slows down, and heart sounds are dull.

　　5. Hypoglycemia symptoms

　　Due to the lack of insulin antagonistic substances in the body and gastrointestinal dysfunction, patients often have low blood sugar, but because the disease progresses slowly, most can tolerate it. Only hunger, sweating, headache, weakness, and restlessness. Severe cases may appear tremors, blurred vision, diplopia, mental disorders, and even convulsions, coma. This disease is particularly sensitive to insulin, even a small dose of injection can cause severe hypoglycemia reaction.

　　6. Mental symptoms

　　Lack of spirit, expressionless, memory decline, dizziness, drowsiness. Some patients have insomnia, irritability, even delirium and mental disorders.

　　7. Adrenal crisis

　　Patients have low resistance, such as infection, trauma, surgery, anesthesia, etc., can trigger acute adrenal crisis.

　　8. Other

　　Patients are very sensitive to anesthetics and sedatives, and small doses can cause drowsiness or coma. Hypogonadism, such as impotence, menstrual disorders, etc.

　　9. Manifestation of primary disease

　　Such as tuberculosis, various autoimmune diseases, and symptoms of glandular dysfunction syndrome.

　　Adrenal cortex insufficiency patients have extremely low immunity, prone to respiratory tract infections, gastrointestinal dysfunction, and even triggering adrenal crisis. Long-term use of hormone replacement therapy has significant side effects, so it should be actively cooperate with traditional Chinese medicine treatment to achieve the best efficacy.

　　Pay attention to rest and avoid overwork of the mind and body. However,动静结合 should be combined with appropriate physical exercise to enhance physical fitness and reduce complications.

　　Avoid the occurrence of conditions such as colds, injuries, surgical stimulation, vomiting and diarrhea, excessive sweating, or excessive cold and heat stimulation.

　　Since adrenal cortex insufficiency may sometimes manifest as asymptomatic, the examination for adrenal cortex insufficiency should be comprehensive. The specific examination methods are as follows.

　　First, general examination

　　1. Blood count examination shows mild normocytic normochromic anemia, with elevated lymphocytes and eosinophils.

　　2. Blood biochemical examination shows that some patients have low serum sodium and high serum potassium. Blood glucose is low, about 1/3 of the cases are below the normal range. Glucose tolerance test shows a flat curve or reactive hypoglycemia.

　　3. Electrocardiogram shows low voltage and flat or inverted T waves, and the Q-T interval may be prolonged.

　　4. X-ray examination shows a reduced cardiac shadow in a vertical position.

　　Second, special examination

　　1. The excretion of free cortisol in urine is lower than normal, and the degree of reduction is parallel to the function of the adrenal cortex.

　　2. The plasma cortisol level is significantly reduced, and the diurnal rhythm is lost.

　　3. ACTH stimulation test is used to check the functional reserve of the adrenal cortex. It can detect patients with mild chronic adrenal cortex insufficiency and differentiate primary chronic adrenal cortex insufficiency from secondary chronic adrenal cortex insufficiency.

　　三、血浆ACTH基础值测定

　　Third, Plasma ACTH Basal Value Measurement

　　The plasma ACTH level in primary adrenal cortical insufficiency is significantly increased, often more than 55 pmol/L (250 pg/ml), usually between 88-440 pmol/L (400-200 pg/ml) (normal value 1.1-11 pmol/L, i.e., 5-50 pg/ml), while the plasma ACTH concentration in secondary adrenal cortical insufficiency is extremely low or does not increase when the blood cortisol level is below normal.

　　Fourth, Etiological Examination

　　Patients with adrenal cortical insufficiency should consume a diet rich in protein, vitamins, and carbohydrates, with more sodium and less potassium to maintain electrolyte balance. The diet should be light and easy to digest, with an emphasis on eating more vegetables and fruits, and a reasonable dietary combination, ensuring adequate nutrition. In addition, patients should avoid spicy, greasy, and cold foods.

　　The treatment for adrenal cortical insufficiency includes emergency treatment during adrenal crisis and routine hormone replacement therapy, as well as etiological treatment.

　　1. Treatment of Adrenal Crisis

　　When there is a high clinical suspicion of acute adrenal crisis, treatment should be started immediately after collecting blood samples for ACTH and cortisol testing. Treatment includes intravenous administration of high-dose glucocorticoids; correcting hypovolemia and electrolyte disorders; systemic supportive therapy and removing the cause.

　　2. Substitution Treatment for Chronic Adrenal Cortex Insufficiency

　　Substitution therapy usually uses oral hydrocortisone or cortisol. The dose varies from person to person and can be appropriately adjusted. If the patient has明显 low blood pressure, additional mineralocorticoid hormones can be added. Patients with secondary adrenal cortical insufficiency do not need mineralocorticoid hormone replacement.