title: Presentation of primary adrenal insufficiency in childhood.
abstract: BACKGROUND
  Primary adrenal insufficiency is usually diagnosed in infancy or adulthood, and cases presenting in childhood have not been systematically reviewed.
  
  
  OBJECTIVE
  Our objective was to determine etiologies, signs, and symptoms of primary adrenal insufficiency presenting in childhood.
  
  
  METHODS
  We conducted a retrospective chart review at a tertiary-care pediatric hospital.
  
  
  METHODS
  Patients were children with corticoadrenal insufficiency, glucocorticoid deficiency, or mineralocorticoid deficiency.
  
  
  RESULTS
  Seventy-seven cases were identified in 1999-2010. Thirty-five had congenital adrenal hyperplasia (CAH) and were not reviewed further. Forty-two patients (20 diagnosed at our institution) had primary adrenal insufficiency. These had etiologies as follows: autoimmune (18), autoimmune polyendocrinopathy syndrome (an additional five), ACTH resistance (four), adrenoleukodystrophy (three), adrenal hypoplasia congenita (two), adrenal hemorrhage (two), IMAGe syndrome (one), and idiopathic (two). Of 20 patients diagnosed at our institution, two were being monitored when adrenal insufficiency developed and were not included in the analysis of presenting signs and symptoms: 13 of 18 patients were hypotensive; 12 of 18 had documented hyperpigmentation. Hyponatremia (<135 mEq/liter) occurred in 16 of 18. However, hyperkalemia (>5.0 mEq/liter) was noted in only nine. Hypoglycemia and ketosis were documented in four of 15 and four of six patients in whom it was sought, respectively. Fifteen patients underwent cosyntropin stimulation testing with median baseline and stimulated cortisol of 1.1 and 1.2 μg/dl, respectively. ACTH and renin were markedly elevated in all patients.
  
  
  CONCLUSIONS
  Hyperkalemia is not a consistent presenting sign of primary adrenal insufficiency in childhood, and its absence cannot rule out this condition. A combination of chronic or subacute clinical symptoms, hypotension, and hyponatremia should raise suspicion of adrenal insufficiency.
authors.affiliation: Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-9063, USA.u
authors.forename: Susan
authors.initials: S
authors.lastname: Hsieh
authors.forename: Perrin C
authors.initials: PC
authors.lastname: White
mesh_terms: D000224:Addison Disease / Q000175:diagnosis* / Q000209:etiology; D000293:Adolescent; D001327:Autoimmune Diseases / Q000150:complications*; D002648:Child; D006801:Humans; D007003:Hypoglycemia / Q000150:complications; D007010:Hyponatremia / Q000150:complications; D007022:Hypotension / Q000150:complications / Q000175:diagnosis; D012189:Retrospective Studies