Table 1.

Clinical Features of Adrenal Insufficiency and Adrenal Crisis

Symptoms	Signs	Routine Laboratory Tests
Adrenal insufficiency
Fatigue	Hyperpigmentation (primary only), particularly of sun-exposed areas, skin creases, mucosal membranes, scars, areola of breast	Hyponatremia
Weight loss	Low blood pressure with increased postural drop	Hyperkalemia
Postural dizziness	Failure to thrive in children	Uncommon: hypoglycemia, hypercalcemia
Anorexia, abdominal discomfort
Adrenal crisis
Severe weakness		Hyponatremia
Syncope	Hypotension	Hyperkalemia
Abdominal pain, nausea, vomiting; may mimic acute abdomen	Abdominal tenderness/guarding	Hypoglycemia
Back pain	Reduced consciousness, delirium	Hypercalcemia
Confusion

Most symptoms are nonspecific and present chronically, often leading to delayed diagnosis. Hyponatremia and, later, hyperkalemia are often triggers to diagnosis, requiring biochemical confirmation of adrenal insufficiency. Hyperpigmentation is a specific sign, but it is variably present in individuals and must be compared with the patient's background pigmentation, such as that in siblings. Adrenal crisis is a medical emergency with hypotension, marked acute abdominal symptoms, and marked laboratory abnormalities, requiring immediate treatment. Continuing effort to prevent adrenal crisis is integral to patient management. Additional symptoms and signs may arise from the underlying cause of adrenal insufficiency, eg, associated autoimmune disorders, neurological features of adrenoleukodystrophy, or disorders that may lead to adrenal infiltration.