The symptoms of adrenal insufficiency depend on the degree of loss of adrenal function and whether mineralocorticoid production is preserved. Clinically, adrenal insufficiency is divided up into acute and chronic.
Adrenal crisis usually presents as shock in two major groups of patients:
The major symptoms of a patient with acute adrenal primary insufficiency are:
The major pathophysiological factor in the precipitation of adrenal crisis is mineralocorticoid deficiency. Adrenal crisis is rare in patients with secondary or tertiary adrenal insufficiency because the renin-angiotensin system functions normally.
Patients with chronic primary adrenal insufficiency have clinical signs and symptoms of glucocorticoids, mineralocorticoid and androgen deficiency. Patients with secondary or tertiary adrenal insufficiency usually maintain mineralocorticoid function.
The most common signs and symptoms of chronic primary adrenal insufficiency are listed below. The clinical features usually have a slow onset with many non-specific symptoms.
The clinical features of secondary adrenal insufficiency are similar to those above except that hyperpigmentation is not present (as ACTH is not elevated) and dehydration does not occur.
A specific sign of primary adrenal insufficiency is increased pigmentation on the exposed areas of the body, points of friction or in palmar creases. Pigmentation is also seen in the buccal mucosa (the lining of the mouth), in scars and in the conjunctivae (the lining of the eye). It is caused by an increased content of melanin (the brown pigment in the skin) which results from the melanocyte-stimulating activity of the POMC-derived peptide MSH (see physiology section).