A 67-Year-Old Woman With Orthostatic Hypotension and Edema

Catherine Anastasopoulou, MD, PhD; Kimberly Lessard, DO


March 08, 2018


The most likely diagnosis for this patient is primary adrenal insufficiency, also known as Addison disease, likely from bilateral adrenal hemorrhage. Given her history of trauma, as well as heparin-induced thrombocytopenia and thrombosis, the changes seen on CT scan at the levels of the adrenals bilaterally are highly suspicious for adrenal hemorrhage. Notable is the markedly low morning cortisol level, which is pathognomonic of adrenal insufficiency. The patient also exhibited several classic signs and symptoms of adrenal insufficiency, including orthostatic hypotension, hyponatremia, and confusion. The hypotension, hyponatremia, and somewhat elevated potassium level are consistent with mineralocorticoid deficiency, as is expected in bilateral adrenal hemorrhage. Normalization of sodium and potassium levels following IV normal saline is also suggestive of adrenal insufficiency.

In general, the presentation of adrenal insufficiency varies according to the level of acuity, the degree of adrenal loss/malfunction, and the level of mineralocorticoid involvement. The onset of adrenal insufficiency may be insidious, unless adrenal crisis is precipitated by stress or illness. In chronic adrenal insufficiency, the most common symptoms include fatigue (84%-95%); anorexia and weight loss (66%-76%); nausea, vomiting, and abdominal pain (49%-62%); and musculoskeletal pain (35%-40%). The most common associated laboratory findings include hyponatremia (70%-80%), hyperkalemia (30%-40%), and anemia (11%-15%). In adrenal crisis, on the other hand, the most common presentation is hypotension or shock. Patients with adrenal crisis may also have nonspecific symptoms similar to those with chronic adrenal insufficiency but may also exhibit fever, confusion, or coma.

Elements of clinical presentation specific to primary adrenal insufficiency, particularly in individuals with long-standing disease, include skin hyperpigmentation related to increased proopiomelanocortin, postural hypotension, and salt craving. Furthermore, in primary adrenal insufficiency, the overall clinical presentation often depends on the etiology. In primary autoimmune adrenalitis, for example, many features of the clinical presentation are similar to that of septic shock.

Bilateral adrenal injury, hemorrhage, or infarction are important diagnoses to consider in the differential etiology of a new primary adrenal insufficiency seen in the setting of blunt trauma or coagulopathy. In bilateral adrenal hemorrhage, most patients develop acute primary adrenal insufficiency that results in hypotension or shock (90%). Other signs and symptoms suggestive of this diagnosis include evidence of occult hemorrhage, such as a drop in hemoglobin level, progressive hyperkalemia and hyponatremia, and refractory volume contraction. Major risk factors for adrenal hemorrhage or infarction include a postoperative state, underlying coagulopathy, and anticoagulant therapy. Bleeding can occur even when anticoagulant therapy is within therapeutic range and can remain isolated to the adrenals.


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