Primary adrenal deficiency

• History / PE:
  Hyperpigmentation (increased ACTH)
  Fatigue
  Orthostatic hypotension
  Weight loss
  GI complaints
• Diagnosis:
  Markedly elevated ACTH
  Eosinophilia
  Hyponatremia , hyperkalemia
  Metabolic acidosis
  Synthetic ACTH stimulation test (confirmatory)
• Complications:
  Addisonian crisis
• Notes:
  Random plasma cortisol > 20 micrograms/dL excludes diagnosis
  Only see hyperpigmentation in primary adrenal insufficiency, secondary to increased levels of ACTH
• Associated With:
  Addison's disease (autoimmune primary adrenocortical deficiency)
  Autoimmune adrenalitis (MCC in developing countries)
  Cessation of exogenous steroid use
  Tuberculosis (see adrenal calcifications)
  CMV
  Waterhouse-Friedrichsen syndrome
  Fungal infections
• Differential Diagnosis:
  Peutz-Jeghers syndrome