Snapshot A 15-year-old male presents to his pediatrician with complaints of fatigue, weight loss, and recurrent nausea and vomitting. On physical exam he appears weak and has skin that appears abnormally tan. A basic metabolic panel reveals hyponatremia and hyperkalemia. Introduction A disorder caused by the destruction of the adrenal cortices Autoimmune destruction accounts for 80% of the spontaneous cases in the U.S. Other causes include congenital enzyme deficiencies hemorrhage (Waterhouse-Friderichsen) TB other infections Leads to loss of cortisol, mineralcorticoids (aldosterone), and catecholamines May be isolated or be a component of a polyglandular autoimmune syndrome Presentation Symptoms fatigue worsened by stress weakness weight loss nausea and vomitting Physical exam increased skin pigmentation (due to elevated pro-opiomelanocortinin → MSH and ACTH) hypotension Evaluation Labs elevated plasma ACTH low cortisol levels in response to ACTH stim test decreased aldosterone leads to hyponatremia hyperkalemia hypoglycemia increased BUN & Cr metabolic acidosis eosinophilia Differential Anorexia nervosa, malabsorption states, occult malignancy, hypoparathyroidism, thyrotoxicosis, panhypopituitaryism Treatment Replace glucocorticoids (prednisone) mineralocorticoids (fludrocortisone) Administer stress dose steroids at time of stress(surgery)