Clinical Case Database / Category: Case Based Discussion

Adrenal physiology & primary adrenal insufficiency

Publication details

Dr Muhammad Ali Karamat, Dr Mohamed Salih Ahmed
Foundation Years Journal, volume 8, issue 5, p.46 (123Doc Education, London, May 2014)


The adrenal gland is composed of adrenal cortex (which is divided into 3 zones in the adult gland) and the adrenal medulla. The cortex produces aldosterone, sex hormones and cortisol, which are all synthesized from cholesterol. Adrenal medulla produces the catecholamines. Cortisol is an endogenous steroid, which is essential for life. Aldosterone promotes sodium retention and potassium elimination by the kidney. Catecholamines stimulate the “fight or fight” reaction.

Adrenal insufficiency is a life-threatening disorder, which is characterized by deficient production or action of glucocorticoids and/or mineralocorticoids and adrenal androgens. Adrenal insufficiency may result from disorders affecting the adrenal cortex (primary), or the anterior lobe of pituitary gland/hypothalamus (secondary).The clinical diagnosis of adrenal insufficiency can be confirmed by demonstrating inappropriately low cortisol secretion.

Treatment of adrenal insufficiency should be initiated as soon as the diagnosis is confirmed, or even sooner if the patient presents in an adrenal crisis. Education to the patient and caregivers is essential part of the management. Acute adrenal crisis is an emergency, which requires prompt intervention, can manifest as a hypovolemic shock. Management is by supportive measures and intravenous glucocorticoid replacement.

Access the Clinical Cases Database

A subscription is required to read the full article. Please subscribe using one of the options below.

Foundation Years Clinical Cases Database£29.006 months
Add to cart
Foundation Years Clinical Cases Database£39.0012 months
Add to cart


Dr Muhammad Ali Karamat

Consultant Physician and Honorary Senior Lecturer,
Diabetes and Endocrinology, Diabetes Center,
Heartlands Hospital,
Bordesley Green East, Birmingham, B9 5SS.

Dr Mohamed Salih Ahmed

SPR Diabetes and Endocrinology,
Birmingham Heartlands Hospital,
Diabetes and endocrinology Centre, Bordesley Green East, Birmingham, B9 5SS.


1. S. Laureti, L. Vecchi, F. Santeusanio, and A. Falorni, “Is the prevalence of Addison’s disease
underestimated?” Journal of Clinical Endocrinology and Metabolism, vol. 84, no. 5, article 1762, 1999.
2. P. M. Zelissen, Addison Patients in the Netherlands: Medical Report of the Survey, Dutch Addison Society, The Hague, The Netherlands, 1994.
3. B. Bleicken, S. Hahner, M. Ventz, and M. Quinkler, “Delayed diagnosis of adrenal insufficiency is common: a cross-sectional study in 216 patients,” The American Journal of the Medical Sciences, vol. 339, no. 6, pp. 525–531, 2010.
4. P. M. Stewart and N. P. Krone, The Adrenal Cortex, Williams Textbook of Endocrinology, Elsevier, London, UK, 12th edition, 2011.
5. S. Hahner, M. Loeffler, B. Bleicken et al., “Epidemiology of adrenal crisis in chronic adrenal
insufficiency: the need for new prevention strategies,” The European Journal of Endocrinology, vol. 162, no. 3, pp. 597–602, 2010.
6. euradrenal_en.html.
7. and http://www.
8. insufficiency.pdf.
9. a grossman,therapy of endocrine disease: perspectives on the management of adrenal insufficiency: clinical insights from across europe, eur j endocrinol. dec 2013; 169(6): r165–r175.
10. Debono M, Ross RJ, Newell-Price J. Inadequacies of glucocorticoid replacement and improvements by physiological circadian therapy. European Journal of Endocrinology. 2009;160:719–729.
11. Johannsson G, Filipsson H, Bergthorsdottir R, Lennernäs H, Skrtic S. Long-acting hydrocortisone for glucocorticoid replacement therapy. Hormone Research. 2007; 68:182–188.
12. Debono M, Ghobadi C, Rostami-Hodjegan A, Huatan H, Campbell MJ, Newell-Price J, Darzy K, Merke DP, Arlt W, Ross RJ. Modified-release hydrocortisone to provide circadian cortisol profiles. Journal of Clinical Endocrinology and Metabolism. 2009; 94:1548–1554.
13. Miller KK, Sesmilo G, Schiller A, Schoenfeld D, Burton S, Klibanski A. Androgen deficiency in women with hypopituitarism. Journal of Clinical Endocrinology and Metabolism. 2001; 86:561–567.
14. Alkatib AA, Cosma M, Elamin MB, Erickson D, Swiglo BA, Erwin PJ, Montori VM. A systematic review and meta-analysis of randomized placebo-controlled trials in DHEA treatment effects on quality of life in women with adrenal insufficiency. Journal of Clinical Endocrinology and Metabolism. 2009; 94:3676–3681


Conflict Of Interest

The Journal requires that authors disclose any potential conflict of interest that they may have. This is clearly stated in the Journal’s published “Guidelines for Authors”. The Journal follows the Guidelines against Conflict of Interest published in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (

Financial Statement

The authors of this article have not been paid. The Journal is financed by subscriptions and advertising. The Journal does not receive money from any other sources. The decision to accept or refuse this article for publication was free from financial considerations and was solely the responsibility of the Editorial Panel and Editor-in-Chief.

Patient Consent statement

All pictures and investigations shown in this article are shown with the patients’ consent. We require Authors to maintain patients’ anonymity and to obtain consent to report investigations and pictures involving human subjects when anonymity may be compromised. The Journal follows the Guidelines of the Uniform Requirements for Manuscripts ( The Journal requires in its Guidelines for Authors a statement from Authors that “the subject gave informed consent”.

Animal & Human Rights

When reporting experiments on human subjects, the Journal requires authors to indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the HelsinkiDeclaration of 1975, as revised in 2008.

About the Clinical Cases Database

T​he Foundation Years Clinical Cases Database is​ a selection of 600 peer-reviewed clinical cases in the field of patient safety and clinical practice, specifically focused on the clinical information needs of junior doctors, based around the Foundation Year Curriculum programme (MMC). The cases have been chosen to align with the Foundation Year Curriculum.

The database is fully searchable, or can be browsed by medical specialty. Abstracts can be read free of charge, however a subscription is required in order to read the complete cases.