The mechanism of adrenal insufficiency in sepsis remains unclear. This form of adrenal insufficiency is termed adrenal insufficiency in critical illness (AICI). While primary adrenal insufficiency typically manifests chronically, acutely inadequate glucocorticoid activity in the setting of severe illness and increased stress has been studied, most notably in sepsis and septic shock. The subsequent deposition of MSH in the skin is responsible for the well-recognized hyperpigmentation of Addison’s patients. The precursor to ACTH, pro-opiomelanocortin (POMC), also contains melanocyte-stimulating hormone (MSH), which is released with the production of ACTH. CT would be the best imaging modality for adrenal assessment but is not necessary for diagnosis.Low plasma cortisol results in increased production of adrenocorticotropic hormone (ACTH) from the anterior pituitary gland, due to the lack of feedback inhibition.

the adrenal glands become atrophic and calcifiedĪdrenal insufficiency is a bilateral process that cannot be diagnosed by imaging alone.

chronic: secondary to chronic autoimmune disorder or chronic granulomatous infection (tuberculosis).

subacute disease (adrenalitis): when the disease has been present for less than two years.

acute: occurs within a few weeks to months and is caused by bilateral adrenal hemorrhage (adrenal apoplexy) or secondary to shock and sepsis or trauma (Addisonian crisis).

The disease course may be either acute, subacute, or chronic 2:

suppression of the adrenal axis by endogenous or exogenous glucocorticoids.

systemic fungal infection: histoplasmosis (most common in the southeastern and south-central United States 1).

adrenal hemorrhage: shock, sepsis ( Waterhouse-Friderichsen syndrome), coagulation disorders, antiphospholipid syndrome, trauma 5.

lung, ovary, kidney, melanoma), lymphoma, and leukemia

granulomatous disease: tuberculosis (the most common infectious cause in developing countries) and sarcoidosis.

idiopathic autoimmune disorders are the most common cause in developed countries (80% of cases) 1.

this indicates decreased ACTH secretion due to pituitary dysfunction.

cortisol levels rise after synthetic ACTH stimulation.

cortisol levels fail to rise after synthetic ACTH stimulation due to the destruction of the adrenal cortex.

adrenocorticotrophic hormone (ACTH) stimulation test:.

chemistry: hyponatremia, hyperkalemia, azotemia, hypercalcemia, hypoglycemia.

chronic stage: progressive lethargy, weakness, cutaneous pigmentation, weight loss.

acute stage: the patient presents with fever, back pain, hypotension, weakness.Secondary adrenal insufficiency due to lack of stimulation of the gland is a more common etiology overall. It may occur from partial or complete destruction of the adrenal cortex, in which case it is termed primary adrenal insufficiency (also known as Addison disease).

Adrenocortical insufficiency