Adrenal atrophy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Pathophysiology

Primary adrenal insufficiency

Primary adrenal insufficiency, which can be acute or chronic, may be caused by the anatomic destruction of the gland. This destruction can have various causes, including tuberculosis (TB) or fungal infection, other diseases infiltrating the adrenal glands, and hemorrhage. However, the most frequent cause is idiopathic atrophy, which is probably autoimmune in origin.

Primary adrenal insufficiency also may be caused by metabolic failure (eg, insufficient hormone production). This failure may be a result of congenital adrenal hyperplasia, enzyme inhibitors (e.g., metyrapone), or cytotoxic agents (e.g., mitotane).

Primary adrenocortical insufficiency is rare and it occurs at any age. The male-to-female ratio is 1:1.

Secondary adrenal insufficiency

Secondary adrenal insufficiency may be caused by hypopituitarism due to hypothalamic-pituitary disease, or it may result from suppression of the hypothalamic-pituitary axis by exogenous steroids or endogenous steroids (i.e., tumor).

Secondary adrenocortical insufficiency is relatively common. Extensive therapeutic use of steroids has greatly contributed to increased incidence.

Acute adrenocortical insufficiency

Adrenal crisis may result from an acute exacerbation of chronic insufficiency, usually caused by sepsis or surgical stress. Acute adrenal insufficiency also can be caused by adrenal hemorrhage (e.g., usually septicemia-induced Waterhouse-Friderichsen syndrome - fulminant meningococcemia) and anticoagulation complications.

Steroid withdrawal is the most common cause of acute adrenocortical insufficiency, and it almost exclusively causes a glucocorticoid deficiency.