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Addison Disease Workup

  • Author: George T Griffing, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
 
Updated: Jul 20, 2016
 

Laboratory Studies

A quick review of the clinical presentation, physical examination findings, and laboratory findings (when available) quickly heightens the index of suspicion and possibly leads to more appropriate tests and diagnosis. A high index of suspicion is necessary for diagnosis.

  • The diagnosis of adrenocortical insufficiency rests on the assessment of the functional capacity of the adrenal cortex to synthesize cortisol. This is accomplished primarily by use of the rapid ACTH stimulation test (Cortrosyn, cosyntropin, or Synacthen).[35]
    • ACTH, through complex mechanisms, activates cholesterol esterase enzymes and leads to the release of free cholesterol from cholesterol esters. It also activates the 20,22-desmolase enzyme, which catalyzes the rate-limiting step in adrenal steroidogenesis and increases the NADPH (nicotinamide adenine dinucleotide phosphate) levels necessary for the various hydroxylation steps in steroidogenesis.
    • Within 15-30 minutes of ACTH infusion, the normal adrenal cortex releases 2-5 times its basal plasma cortisol output.
    • Although ACTH stimulation is not normally the major stimulus for aldosterone production, it increases aldosterone production to peak levels within 30 minutes. This response, however, is affected by dietary sodium intake.
    • An increase in the plasma cortisol and aldosterone levels above basal levels after ACTH injection reflects the functional integrity of the adrenal cortex.
  • Performing the rapid adrenocorticotrophic hormone test[36]
    • Blood is drawn in 2 separate tubes for baseline cortisol and aldosterone values.
    • Synthetic ACTH (1-24 amino acid sequence) in a dose of 250 mcg (0.25 mg) is given IM or IV. Smaller doses of synthetic ACTH, as low as 1 mcg, have been used with accuracy approaching the standard test. Proponents of this modified test argue that a dose of 1 mcg or lower is more physiologic, whereas the 250-mcg dose is pharmacologic. However, the modified test is more sensitive only for the 30-minute samples, not the 60-minute samples.
    • Thirty or 60 minutes after the ACTH injection, 2 more blood samples are drawn; one for cortisol and one for aldosterone. No significant reason exists to draw both the 30-minute and 60-minute samples because the sensitivity of the 30-minute value for accurate diagnosis is well documented. The baseline and 30-minute samples usually are adequate to establish the diagnosis.
  • Interpreting the rapid adrenocorticotrophic hormone test[37, 38, 39, 40]
    • Two criteria are necessary for diagnosis: (1) an increase in the baseline cortisol value of 7 mcg/dL or more and (2) the value must rise to 20 mcg/dL or more in 30 or 60 minutes, establishing normal adrenal glucocorticoid function.
    • A low aldosterone value of less than 5 ng/100 mL that fails to double or increase by at least 4 ng/100 mL 30 minutes after ACTH administration denotes abnormal mineralocorticoid function of the adrenal cortex.
    • The 30-minute aldosterone value is more sensitive than the 60-minute value because aldosterone levels actually have been shown to decrease in the 60-minute sample.
    • The absolute 30- or 60-minute cortisol value carries more significance than the incremental value, especially in patients who may be in great stress and at their maximal adrenal output. These patients may not show a significant increase in cortisol output with ACTH stimulation.
    • A normal 30- or 60-minute rapid ACTH test excludes Addison disease but may not adequately exclude mild impairment of the hypothalamic pituitary adrenal axis in secondary adrenal insufficiency.
    • In patients with Addison disease, both cortisol and aldosterone show minimal or no change in response to ACTH, even with prolonged ACTH stimulation tests lasting 24-48 hours.
    • When the results of the rapid ACTH test are equivocal and do not meet the 2 criteria mentioned above, further testing might be required to distinguish Addison disease from secondary adrenocortical insufficiency. Plasma ACTH values and prolonged ACTH stimulation tests may be useful in making this distinction.
    • ACTH levels often are elevated to higher than 250 pg/mL in patients with Addison disease. However, ACTH is unstable in plasma, and specimen collection and storage may require special attention. The specimen should be collected in iced anticoagulated plastic containers and frozen immediately.
    • Importantly, note that ACTH levels also may be high in patients recovering from steroid-induced secondary adrenocortical insufficiency and in patients with ACTH-refractory syndromes.
    • ACTH-inducing tests such as metyrapone stimulation and insulin-induced hypoglycemia, which may be useful in the evaluation of some cases of secondary adrenocortical insufficiency, have no role in the diagnosis of Addison disease and may in fact be lethal to the patient with Addison disease.
  • In acute adrenal crisis, where treatment should not be delayed in order to do the tests, a blood sample for a random plasma cortisol level should be drawn prior to starting hydrocortisone replacement.
    • A random plasma cortisol value of 25 mcg/dL or greater effectively excludes adrenal insufficiency of any kind. However, a random cortisol value in patients who are acutely ill should be interpreted with caution and in correlation with the circumstances of each individual patient. Random cortisol levels should also be interpreted cautiously in critically ill patients with hypoproteinemia (serum albumin < 2.5 g/dL). Approximately 40% of these patients will have baseline and cosyntropin-stimulated cortisol levels below the reference range even though the patients have normal adrenal function (as evidenced by the measurement of free cortisol levels). This phenomenon is because more than 90% of circulating cortisol in human serum is protein bound.
    • Cortisol is known to be elevated by stress, but exactly how high it should rise to constitute a normal response in times of severe stress is not known.
    • An abnormal test result should prompt a proper evaluation of the hypothalamic pituitary adrenal axis after the patient's condition improves before committing a patient to lifelong steroid replacement.
    • In order to perform the ACTH stimulation test in this situation, the patient should be switched to dexamethasone and then tested 24-36 hours later. Dexamethasone does not interfere with the cortisol assay, as does hydrocortisone or prednisone. However, dexamethasone may interfere with interpretation of the random cortisol value drawn after dexamethasone already has been initiated. Dexamethasone also does not have any mineralocorticoid activity, which may be needed in patients with Addison disease.
  • Other laboratory tests
    • Comprehensive metabolic panel
      • The most prominent findings are hyponatremia, hyperkalemia, and a mild non–anion-gap metabolic acidosis due to the loss of the sodium-retaining and potassium and hydrogen ion-secreting action of aldosterone.
      • Urinary and sweat sodium also may be elevated.
      • The most consistent finding is elevated blood urea nitrogen (BUN) and creatinine due to the hypovolemia, a decreased glomerular filtration rate, and a decreased renal plasma flow.
      • Hypercalcemia, the cause of which is not well understood, may be present in a small percentage of patients. However, hypocalcemia could occur in patients with Addison disease accompanied by idiopathic hypoparathyroidism.
      • Hypoglycemia may be present in fasted patients, or it may occur spontaneously. It is caused by the increased peripheral utilization of glucose and increased insulin sensitivity. It is more prominent in children and in patients with secondary adrenocortical insufficiency.
      • Liver function tests may reveal a glucocorticoid-responsive liver dysfunction.
    • CBC count
      • CBC count may reveal a normocytic normochromic anemia, which, upon initial presentation, may be masked by dehydration and hemoconcentration. Relative lymphocytosis and eosinophilia may be present.
      • All of these findings are responsive to glucocorticoid replacement.
    • Thyroid-stimulating hormone[41]
      • Increased thyroid-stimulating hormone (TSH), with or without low thyroxine, with or without associated thyroid autoantibodies, and with or without symptoms of hypothyroidism, may occur in patients with Addison disease and in patients with secondary adrenocortical insufficiency due to isolated ACTH deficiency. These findings may be slowly reversible with cortisol replacement.[42]
      • In the setting of both adrenocortical insufficiency and hypothyroidism that requires treatment, corticosteroids should be given before thyroid hormone replacement to avoid precipitating an acute adrenal crisis.
  • Autoantibody testing - Thyroid autoantibodies, specifically antithyroglobulin (anti-Tg) and antimicrosomal or antithyroid peroxidase (anti-TPO) antibodies, and/or adrenal autoantibodies may be present.
  • Prolactin testing
    • Modest hyperprolactinemia has been reported in cases of Addison disease and also in secondary adrenocortical insufficiency. It is responsive to glucocorticoid replacement.
    • The cause of the hyperprolactinemia is thought to be the hyperresponsiveness of the lactotroph to thyrotropin-releasing hormone (TRH) in the absence of the steroid-induced or steroid-enhanced hypothalamic dopaminergic tone.
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Imaging Studies

Chest radiograph:

  • The chest radiogram may be normal but often reveals a small heart.
  • Stigmata of earlier infection or current evidence of TB or fungal infection may be present when this is the cause of Addison disease.

CT scan:[11, 43]

  • Abdominal CT scan may be normal but may show bilateral enlargement of the adrenal glands in patients with Addison disease because of TB, fungal infections, adrenal hemorrhage, or infiltrating diseases involving the adrenal glands.
  • In Addison disease due to TB or histoplasmosis, evidence of calcification involving both adrenal glands may be present.
  • In idiopathic autoimmune Addison disease, the adrenal glands usually are atrophic.
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Other Tests

ECG may show low-voltage QRS tracing with nonspecific ST-T wave changes and/or changes due to hyperkalemia. These changes are reversible with glucocorticoid replacement.

Sputum examination, examination of gastric washings for acid-fast and alcohol-fast bacilli, and a Mantoux or purified protein derivative (PPD) skin test may be needed if TB is thought to be the cause.

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Histologic Findings

In cases due to idiopathic autoimmune adrenocortical atrophy, the adrenal glands usually are atrophic, with marked lymphocytic infiltration and fibrosis of the adrenal capsule. The adrenal medulla is spared.

In cases due to TB, the adrenal glands may be enlarged and contain caseating granulomas. Diffuse calcification may be evident, and the adrenal medulla usually is involved.[11]

In patients with AIDS, the adrenal glands may show necrotizing inflammation, hemorrhage, and infarction.

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Contributor Information and Disclosures
Author

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sylvester Odeke, MD, FACE Vidant Medical Group Endocrinology, Diabetes & Metabolism, Greenville, NC

Sylvester Odeke, MD, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, North Carolina Medical Society, American College of Endocrinology

Disclosure: Nothing to disclose.

Steven B Nagelberg, MD Clinical Professor, Department of Medicine, Division of Endocrinology and Metabolism, Drexel University College of Medicine

Steven B Nagelberg, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, American Medical Association, Endocrine Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS Professor of Medicine (Endocrinology, Adj), Johns Hopkins School of Medicine; Affiliate Research Professor, Bioinformatics and Computational Biology Program, School of Computational Sciences, George Mason University; Principal, C/A Informatics, LLC

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Nutrition, American Society for Bone and Mineral Research, International Society for Clinical Densitometry, American College of Endocrinology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Informatics Association, Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

This chapter is dedicated to the late Dr. James C. Melby.

References
  1. Addison T. On the Constitutional and Local Effects of Disease of the Supra-renal Capsules. London, UK: Samuel Highley; 1855.

  2. Olafsson AS, Sigurjonsdottir HA. INCREASING PREVALENCE OF ADDISON DISEASE: RESULTS FROM A NATIONWIDE STUDY. Endocr Pract. 2016 Jan. 22 (1):30-5. [Medline].

  3. Kyriazopoulou V. Glucocorticoid replacement therapy in patients with Addison's disease. Expert Opin Pharmacother. 2007 Apr. 8(6):725-9. [Medline].

  4. Bergthorsdottir R, Leonsson-Zachrisson M, Oden A, et al. Premature mortality in patients with Addison's disease: a population-based study. J Clin Endocrinol Metab. 2006 Dec. 91(12):4849-53. [Medline]. [Full Text].

  5. Hemminki K, Li X, Sundquist J, et al. Subsequent autoimmune or related disease in asthma patients: clustering of diseases or medical care?. Ann Epidemiol. 2010 Mar. 20(3):217-22. [Medline].

  6. White K, Arlt W. Adrenal crisis in treated Addison's disease: a predictable but under-managed event. Eur J Endocrinol. 2010 Jan. 162(1):115-20. [Medline].

  7. Barnett AH, Espiner EA, Donald RA. Patients presenting with Addison's disease need not be pigmented. Postgrad Med J. 1982 Nov. 58(685):690-2. [Medline].

  8. McBrien DJ. Steatorrhea in Addison's disease. Lancet. 1963. Vol I:25-6.

  9. Van Dellen RG, Purnell DC. Hyperkalemic paralysis in Addison's disease. Mayo Clin Proc. 1969 Dec. 44(12):904-14.

  10. Likhari T, Magzoub S, Griffiths MJ, et al. Screening for Addison's disease in patients with type 1 diabetes mellitus and recurrent hypoglycaemia. Postgrad Med J. 2007 Jun. 83(980):420-1. [Medline].

  11. Guo YK, Yang ZG, Li Y, et al. Addison's disease due to adrenal tuberculosis: contrast-enhanced CT features and clinical duration correlation. Eur J Radiol. 2007 Apr. 62(1):126-31. [Medline].

  12. Husebye E, Lovas K. Pathogenesis of primary adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2009 Apr. 23(2):147-57. [Medline].

  13. Husebye ES, Bratland E, Bredholt G, et al. The substrate-binding domain of 21-hydroxylase, the main autoantigen in autoimmune Addison's disease, is an immunodominant T cell epitope. Endocrinology. 2006 May. 147(5):2411-6. [Medline]. [Full Text].

  14. Wolff AS, Myhr KM, Vedeler CA, et al. Fc-gamma receptor polymorphisms are not associated with autoimmune Addison's disease. Scand J Immunol. 2007 Jun. 65(6):555-8. [Medline].

  15. Roycroft M, Fichna M, McDonald D, et al. The tryptophan 620 allele of the lymphoid tyrosine phosphatase (PTPN22 gene) predisposes to autoimmune Addison's disease. Clin Endocrinol (Oxf). 2008 Aug 15. [Medline].

  16. Elfstrom P, Montgomery SM, Kampe O, et al. Risk of primary adrenal insufficiency in patients with celiac disease. J Clin Endocrinol Metab. 2007 Sep. 92(9):3595-8. [Medline]. [Full Text].

  17. Betterle C, Lazzarotto F, Spadaccino AC, et al. Celiac disease in North Italian patients with autoimmune Addison's disease. Eur J Endocrinol. 2006 Feb. 154(2):275-9. [Medline].

  18. Biagi F, Campanella J, Soriani A, et al. Prevalence of coeliac disease in Italian patients affected by Addison's disease. Scand J Gastroenterol. 2006 Mar. 41(3):302-5. [Medline].

  19. Wolff AS, Erichsen MM, Meager A, et al. Autoimmune polyendocrine syndrome type 1 in Norway: phenotypic variation, autoantibodies, and novel mutations in the autoimmune regulator gene. J Clin Endocrinol Metab. 2007 Feb. 92(2):595-603. [Medline].

  20. Magitta NF, Boe Wolff AS, Johansson S, et al. A coding polymorphism in NALP1 confers risk for autoimmune Addison's disease and type 1 diabetes. Genes Immun. 2008 Oct 23. [Medline].

  21. Gombos Z, Hermann R, Kiviniemi M, et al. Analysis of extended human leukocyte antigen haplotype association with Addison's disease in three populations. Eur J Endocrinol. 2007 Dec. 157(6):757-61. [Medline].

  22. Glasgow BJ, Steinsapir KD, Anders K, et al. Adrenal pathology in the acquired immune deficiency syndrome. Am J Clin Pathol. 1985 Nov. 84(5):594-7. [Medline].

  23. Greene LW, Cole W, Greene JB, et al. Adrenal insufficiency as a complication of the acquired immunodeficiency syndrome. Ann Intern Med. 1984 Oct. 101(4):497-8. [Medline].

  24. Membreno L, Irony I, Dere W, et al. Adrenocortical function in acquired immunodeficiency syndrome. J Clin Endocrinol Metab. 1987 Sep. 65(3):482-7. [Medline].

  25. Mukhopadhya A, Danda S, Huebner A, et al. Mutations of the AAAS gene in an Indian family with Allgrove's syndrome. World J Gastroenterol. 2006 Aug 7. 12(29):4764-6. [Medline].

  26. Migeon CJ, Kenny EM, Kowarski A, et al. The syndrome of congenital adrenocortical unresponsiveness to ACTH. Report of six cases. Pediatr Res. 1968 Nov. 2(6):501-13. [Medline].

  27. Babu K, Murthy KR, Babu N, et al. Triple A syndrome with ophthalmic manifestations in two siblings. Indian J Ophthalmol. 2007 Jul-Aug. 55(4):304-6. [Medline]. [Full Text].

  28. Mukherjee S, Newby E, Harvey JN. Adrenomyeloneuropathy in patients with 'Addison's disease': genetic case analysis. J R Soc Med. 2006 May. 99(5):245-9. [Medline].

  29. Dias RP, Chan LF, Metherell LA, et al. Isolated Addison's disease is unlikely to be caused by mutations in MC2R, MRAP or STAR, three genes responsible for familial glucocorticoid deficiency. Eur J Endocrinol. 2010 Feb. 162(2):357-9. [Medline]. [Full Text].

  30. Baker BY, Lin L, Kim CJ, et al. Nonclassic congenital lipoid adrenal hyperplasia: a new disorder of the steroidogenic acute regulatory protein with very late presentation and normal male genitalia. J Clin Endocrinol Metab. 2006 Dec. 91(12):4781-5. [Medline]. [Full Text].

  31. Dackis CA, Gurpegui M, Pottash AL, et al. Methadone induced hypoadrenalism. Lancet. 1982 Nov 20. 2(8308):1167.

  32. Sekiguchi Y, Hara Y, Matsuoka H, et al. Sibling cases of Addison's disease caused by DAX-1 gene mutations. Intern Med. 2007. 46(1):35-9. [Medline]. [Full Text].

  33. Elansary EH, Earis JE. Rifampicin and adrenal crisis. Br Med J (Clin Res Ed). 1983 Jun 11. 286(6381):1861-2.

  34. Kyriazopoulou V, Parparousi O, Vagenakis AG. Rifampicin-induced adrenal crisis in addisonian patients receiving corticosteroid replacement therapy. J Clin Endocrinol Metab. 1984 Dec. 59(6):1204-6.

  35. Oelkers W, Diederich S, Bahr V. Diagnosis and therapy surveillance in Addison's disease: rapid adrenocorticotropin (ACTH) test and measurement of plasma ACTH, renin activity, and aldosterone. J Clin Endocrinol Metab. 1992 Jul. 75(1):259-64. [Medline]. [Full Text].

  36. Demers LM, Whitley RJ. Function of the adrenal cortex: protocol for the rapid ACTH test. In: Burtis CA, Ashwood ER, eds. Tietz Textbook of Clinical Chemistry. 3rd ed. Philadelphia, Pa: WB Saunders; 1999. Vol 43: 1530-60.

  37. Dickstein G, Shechner C, Nicholson WE, et al. Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test. J Clin Endocrinol Metab. 1991 Apr. 72(4):773-8. [Medline].

  38. Dluhy RG, Himathongkam T, Greenfield M. Rapid ACTH test with plasma aldosterone levels. Improved diagnostic discrimination. Ann Intern Med. 1974 Jun. 80(6):693-6.

  39. Lindholm J, Kehlet H. Re-evaluation of the clinical value of the 30 min ACTH test in assessing the hypothalamic-pituitary-adrenocortical function. Clin Endocrinol (Oxf). 1987 Jan. 26(1):53-9. [Medline].

  40. May ME, Carey RM. Rapid adrenocorticotropic hormone test in practice. Retrospective review. Am J Med. 1985 Dec. 79(6):679-84. [Medline].

  41. Barnett AH, Donald RA, Espiner EA. High concentrations of thyroid-stimulating hormone in untreated glucocorticoid deficiency: indication of primary hypothyroidism?. Br Med J (Clin Res Ed). 1982 Jul 17. 285(6336):172-3. [Medline].

  42. Gharib H, Hodgson SF, Gastineau CF, et al. Reversible hypothyroidism in Addison's disease. Lancet. 1972 Oct 7. 2(7780):734-6. [Medline].

  43. Ma ES, Yang ZG, Li Y, et al. Tuberculous Addison's disease: morphological and quantitative evaluation with multidetector-row CT. Eur J Radiol. 2007 Jun. 62(3):352-8. [Medline].

  44. Lovas K, Husebye ES. Continuous subcutaneous hydrocortisone infusion in Addison's disease. Eur J Endocrinol. 2007 Jul. 157(1):109-12. [Medline].

  45. Debono M, Ross RJ. Doses and steroids to be used in primary and central hypoadrenalism. Ann Endocrinol (Paris). 2007 Sep. 68(4):265-7. [Medline].

  46. Reisch N, Arlt W. Fine tuning for quality of life: 21st century approach to treatment of Addison's disease. Endocrinol Metab Clin North Am. 2009 Jun. 38(2):407-18, ix-x. [Medline].

  47. Lovas K, Gjesdal CG, Christensen M, et al. Glucocorticoid replacement therapy and pharmacogenetics in Addison's disease: effects on bone. Eur J Endocrinol. 2009 Jun. 160(6):993-1002. [Medline].

  48. Chandy DD, Bhatia E. BONE MINERAL DENSITY IN PATIENTS WITH ADDISON DISEASE ON REPLACEMENT THERAPY WITH PREDNISOLONE. Endocr Pract. 2016 Apr. 22 (4):434-9. [Medline].

  49. Bethune JE. The diagnosis and treatment of adrenal insufficiency. In: De Groot LJ, ed. Endocrinology. 2nd ed. Philadelphia, Pa: WB Saunders; 1989. Vol 2: 1647-59.

  50. Bethune JE. The Adrenal cortex: a scope monograph. Kalamazoo, Mich: Upjohn Co; 1974.

  51. Burke CW. Adrenocortical insufficiency. Clin Endocrinol Metab. 1985 Nov. 14(4):947-76.

  52. Charmandari E, Nicolaides NC, Chrousos GP. Adrenal insufficiency. Lancet. 2014 Jun 21. 383(9935):2152-67. [Medline].

  53. Christiansen JJ, Djurhuus CB, Gravholt CH, et al. Effects of cortisol on carbohydrate, lipid, and protein metabolism: studies of acute cortisol withdrawal in adrenocortical failure. J Clin Endocrinol Metab. 2007 Sep. 92(9):3553-9. [Medline]. [Full Text].

  54. Coco G, Dal Pra C, Presotto F, et al. Estimated risk for developing autoimmune Addison's disease in patients with adrenal cortex autoantibodies. J Clin Endocrinol Metab. 2006 May. 91(5):1637-45. [Medline]. [Full Text].

  55. Donckier JE, Lacrosse M, Michel L. Bilateral adrenal lymphoma with Addison's disease : a surgical pitfall. Acta Chir Belg. 2007 Mar-Apr. 107(2):219-21. [Medline].

  56. Eisenbarth GS, Wilson PW, Ward F, et al. The polyglandular failure syndrome: disease inheritance, HLA type, and immune function. Ann Intern Med. 1979 Oct. 91(4):528-33. [Medline].

  57. Symington T, ed. Functional Pathology of the Adrenal Gland. Edinburgh, Scotland: Churchill Livingstone; 1969.

  58. Gordon WH, Dluhy RG. Diseases of the adrenal cortex. In: Fauci A, Brunwald E, Martin JB, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998. Vol 332: 2035-54.

  59. Hamrahian AH, Oseni TS, Arafah BM. Measurements of serum free cortisol in critically ill patients. N Engl J Med. 2004 Apr 15. 350(16):1629-38.

  60. Kaplan NM. The adrenal glands. In: Griffin JE, Ojeda S, eds. Textbook of Endocrine Physiology. 3rd ed. Oxford, UK: Oxford University Press; 1996. 284-313.

  61. Kasperlik-Zaluska AA, Migdalska B, Czarnocka B, Drac-Kaniewska J, Niegowska E, Czech W. Association of Addison's disease with autoimmune disorders--a long-term observation of 180 patients. Postgrad Med J. 1991 Nov. 67(793):984-7. [Medline]. [Full Text].

  62. Lever EG, McKerron CG. Auto-immune Addison's disease associated with hyperprolactinaemia. Clin Endocrinol (Oxf). 1984 Oct. 21(4):451-7. [Medline].

  63. Lovas K, Thorsen TE, Husebye ES. Saliva cortisol measurement: simple and reliable assessment of the glucocorticoid replacement therapy in Addison's disease. J Endocrinol Invest. 2006 Sep. 29(8):727-31. [Medline].

  64. Mason AS, Meade TW, Lee JA, et al. Epidemiological and clinical picture of Addison's disease. Lancet. 1968 Oct 5. 2(7571):744-7. [Medline].

  65. Meakin JW, Nelson DH, Thorn GW. Addison's disease in two brothers. J Clin Endocrinol Metab. 1959 Jun. 19(6):726-31.

  66. Nieman LK, Chanco Turner ML. Addison's disease. Clin Dermatol. 2006 Jul-Aug. 24(4):276-80. [Medline].

  67. Norbiato G, Galli M, Righini V, et al. The syndrome of acquired glucocorticoid resistance in HIV infection. Baillieres Clin Endocrinol Metab. 1994 Oct. 8(4):777-87. [Medline].

  68. Pombo M, Devesa J, Taborda A, et al. Glucocorticoid deficiency with achalasia of the cardia and lack of lacrimation. Clin Endocrinol (Oxf). 1985 Sep. 23(3):237-43. [Medline].

  69. Rose LI, Williams GH, Jagger PI, et al. The 48-hour adrenocorticotrophin infusion test for adrenocortical insufficiency. Ann Intern Med. 1970 Jul. 73(1):49-54.

  70. Sloper JC. The pathology of the adrenals, thymus and certain other endocrine glands in Addison's disease: an analysis of 37 necropsies. Proc R Soc Med. 1955 Aug. 48(8):625-8.

  71. Torrejon S, Webb SM, Rodriguez-Espinosa J, et al. Long-lasting subclinical Addison's disease. Exp Clin Endocrinol Diabetes. 2007 Sep. 115(8):530-2. [Medline].

  72. Walter M, McDonald CG, Paty BW, et al. Prevalence of autoimmune diseases in islet transplant candidates with severe hypoglycaemia and glycaemic lability: previously undiagnosed coeliac and autoimmune thyroid disease is identified by screening. Diabet Med. 2007 Feb. 24(2):161-5. [Medline].

  73. Waterhouse R. A case of suprarenal apoplexy. Lancet. 1911. Vol 3:577-8.

  74. Wood JB, Frankland AW, James VH, et al. A rapid test of adrenocortical function. Lancet. 1965 Jan 30. 191:243-5.

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