Primary Adrenal Insufficiency

Case Discussion
Group 6:
Arci Bella
Rhea Ayore
Maanne Lucenas
Liza Torrico II
Nisvickson Basulgan
Lance Montemayor
The adrenal glands are paired, retroperitoneal organs
located superior and medial to the kidneys at the level
of the eleventh ribs. The normal adrenal gland
measures 5 × 3 × 1 cm and weighs 4 to 5 g. The right
gland is pyramidal shaped and lies in close proximity to
the right hemidiaphragm, liver, and inferior vena cava
(IVC).
Case: Bea Chiu, 41 y.o., Female
Pertinent symptoms:
• Weight loss of 15 lbs
• Extreme fatigue
• Decreased body hair in the axillary and pubic
regions
• Skin was very tanned
• No menstrual period for 3 months
Pertinent signs:
• Appeared very thin
• Sunken eyes
• Decreased skin turgor
• BP: 90/60 (supine), 70/35 (upright)
• Pulse rate: 120 beats/min
• Deeply pigmented skin (especially nipples and
the creases in the palms of her hands)
Venous Blood
• Na+ 126 mEq/L (decreased)
• K+ 5.7 mEq/L (increased)
• Osmolarity 265 mOsm/L (decreased)
• Glucose (fasting) 50 mg/dL (decreased)
• Cortisol (decreased)
• Aldosterone decreased\ACTH (increased)
Arterial Blood
• pH 7.32 (decreased)
• HCO3 18 mEq/L (decreased)
1. Why were Bea’s serum cortisol,
aldosterone, and ACTH levels consistent
with primary adrenocortical
insufficiency? How did her negative
response to the ACTH stimulation test
confirm this diagnosis?
Reference: Guyton and Hall Textbook of Medical Physiology p.934
Reference: Guyton and Hall Textbook of Medical Physiology p.934
Reference: Harrison’s principles of Internal Medicine p. 2325
2. How did adrenocortical insufficiency
cause Bea’s decreased arterial pressure?
Why did her blood pressure decrease
further when she moved from a supine
position to a standing position?
• The Zona Glomerulosa is probably destroyed
or affected thus, affecting the production of
aldosterone which is a major contributor in
the balance of potassium and sodium in the
blood. Decreasing the level of aldosterone
results in decrease level of sodium. With less
sodium in the blood water moves out of the
blood vessels which result in low blood
volume thus decreases the arterial pressure.
• When you stand up, gravity causes blood to
pool in your legs and abdomen. This decreases
blood pressure because there's less blood
circulating back to your heart. In our patient's
case having a low blood volume further
aggravates the decrease in blood volume
pressure when changing in position.
3. Why was her pulse rate increased?
Why was her pulse rate higher when she
was standing than when she was
supine?
• As the extracellular fluid becomes depleted, plasma
volume falls, red blood cell concentration rises
markedly, cardiac output and blood pressure
decrease.
• Hence, with this decrease of blood pressure, the

heart tries to compensate by increasing contractility
and thereby presents an increase in pulse rate.
Source: Guyton and Hall Textbook of Medical Physiology p.934

• Normally, the gravitational stress of suddenly
standing causes blood to pool in the capacitance
veins of the legs and trunk. The subsequent transient
decrease in venous return reduces cardiac output
and thus BP. In response, baroreceptors in the aortic
arch and carotid bodies activate autonomic reflexes
to rapidly return BP to normal.
• The sympathetic nervous system increases heart
rate and contractility and increases vasomotor tone
of the capacitance vessels hence an increase on the
pulse rate. Simultaneous parasympathetic (vagal)
inhibition also increases heart rate.
Source: Guyton and Hall Textbook of Medical Physiology p.934-935

4. Why was Bea’s fasting blood glucose
level lower than normal and why did se
have decreased pubic and axillary hair?
• The adrenal glands also produce androgen
(the most important of which is
dehydroepiandrosterone, DHEA), a steroid
hormone that controls the development of
certain secondary sexual characteristics such
as hair growth. Deficiency of androgen can
cause loss of body hair and diminished sex
drive in women.
source: https://rarediseases.org/rare-diseases/addisons-disease/
• Loss of cortisol secretion makes it impossible
for a person with Addison’s disease to
maintain normal blood glucose concentration
between meals because he or she cannot
synthesize against significant quantities of
glucose by gluconeogenesis.

5. Why was her serum K+ concentration
elevated (hyperkalemia)?
6. Why was her serum Na+ concentration

decreased (hyponatremia)?
• Hyponatremia is a characteristic biochemical
feature in primary adrenal insufficiency and is
found in 80% of patients at presentation.
• Hyperkalemia is present in 40% of patients at
initial diagnosis.
7. Why did Bea’s skin appear tanned
(hyperpigmentation)?
• Caused by excess ACTH stimulation of
melanocytes.
• Hyperpigmentation is most pronounced in
skin areas exposed to increased friction or
shear stress and is increased by sunlight.
• When cortisol secretion is depressed, negative
feedback is also depressed both to the
hypothalamus and anterior pituitary. Increased
ACTH secretion with simultaneous secretion of
MSH.
• Tremendous amounts of ACTH can stimulate
formation of melanin.
• It is especially deposited in thin skin areas such as
in the lips and nipples

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Case Discussion

• Hence, with this decrease of blood pressure, the

Source: Guyton and Hall Textbook of Medical Physiology p.934

Source: Guyton and Hall Textbook of Medical Physiology p.934-935

Source: Guyton and Hall Textbook of Medical Physiology p.934-935

6. Why was her serum Na+ concentration

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