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Diagnosis requires demonstration of decreased corticosteroid concentrations in plasma and an accurate classification of adrenal hypofunction as primary or secondary. If secondary adrenal hypofunction is suspected, the metyrapone test is indicated. This test requires oral or I.V. administration of metyrapone, which blocks cortisol production and should stimulate the release of corticotropin from the hypothalamic-pituitary system. In adrenal hypofunction, the hypothalamic-pituitary system responds normally, and plasma reveals high levels of corticotropin; however, plasma levels of cortisol precursor and urinary concentrations of 17-hydroxycorticosteroids don’t rise.
If either primary or secondary adrenal hypofunction is suspected, a short corticotropin stimulation test may be done. If both corticotropin and cortisol are low, the long corticotropin test may be done. The test involves I.V. administration of corticotropin over 6 to 8 hours, after samples have been obtained to determine baseline plasma cortisol and 24-hour urine cortisol levels. In adrenal hypofunction, plasma and urine cortisol levels fail to rise normally in response to corticotropin; in secondary hypofunction, repeated doses of corticotropin over successive days produce a gradual increase in cortisol levels until normal values are reached.
In a patient with typical addisonian symptoms, the following laboratory findings strongly suggest acute adrenal hypofunction:
❑ decreased cortisol levels in plasma (less than 10 mcg/dl in the morning, with lower levels in the evening); however, this test is time-consuming, and emergency therapy shouldn’t be postponed for test results
❑ decreased serum sodium and fasting blood glucose levels
❑ increased serum potassium and blood urea nitrogen levels
❑ elevated hematocrit and lymphocyte and eosinophil counts
❑ X-rays showing a small heart and adrenal calcification.
Source: Professional Guide to Diseases (Eighth Edition), 2005
The diagnosis of adrenal insufficiency should be made only with corticotropin stimulation testing to assess adrenal reserve capacity.
The corticotropin stimulation test involves I.M. or I.V. administration of cosyntropin with samples obtained 60 minutes later. Cortisol levels should be greater than 18 µg/dl. If the result is abnormal, primary and secondary adrenal insufficiency can be distinguished by measuring aldosterone levels from the same blood sample. With secondary adrenal insufficiency, the aldosterone level is normal (greater than or equal to 5 ng/dl). Baseline plasma cortisol levels may also be obtained. With Addison’s disease, plasma and urine cortisol levels fail to rise normally in response to corticotropin; with secondary hypofunction, repeated doses of corticotropin over successive days produce a gradual increase in cortisol levels until normal values are reached.
Source: Handbook of Diseases, 2003
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