The clinical presentation of adrenal insufficiency is variable, depending on its pathogenesis, and ranges from vague non-specific symptoms to a sudden cardiovascular collapse (adrenal crisis). Chronic hypoadrenalism
The onset of clinical manifestation is usually insidious with gradual development of signs and symptoms, each of which is non-specific alone. Increasing weakness, fatigue, lassitude, anorexia, myalgia, and weight loss are the first symptoms in gradually developing primary hypoadrenalism. Weight loss, which is mostly due to anorexia but can also be caused by dehydration, may be substantial. Vomiting and constipation, apathy, depression, and even psychosis may also occur. Vomiting and abdominal pain often herald an adrenal crisis. In some instances a history of craving for salt or salty foods may be present. Blood pressure is usually low and signs of dehydration are common. Hyperpigmentation, particularly of the lips, buccal mucosa, gingiva, palmar and plantar creases, areolas, and previous scars, is characteristic of primary hypoadrenalism but may be absent in hypoadrenalism of recent onset. Hyperpigmentation may be generalized, creating a darkish cast to the skin resembling a sun tan. The ACTH precursor pro-opiomelanocortin, which is produced by the pituitary, is also the precursor of b-melanocyte-stimulating hormone which also increases. This explains the hyperpigmentation observed in (long-standing) Addison's disease which is absent in secondary/tertiary hypoadrenalism. In many instances patients with chronic hypoadrenalism may be able to survive in the basal state but develop an adrenal crisis following trauma or infection. The main symptoms and signs of chronic hypoadrenalism are summarized in Table 1...
Table 1 Clinical manifestations of chronic hypoadrenalism
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