Adrenalitis- Causes, Symptoms, Investigations, and Treatment

Introduction

Adrenal glands are triangular-shaped glands situated above the kidneys. It is an endocrine gland. They secrete hormones that help chiefly regulate the metabolism, blood pressure, immunity, pregnancy, and stress response. It also takes part in other vital functions of the body. One of the most important functions is the release of its hormones during stressful situations. It has two parts: the adrenal medulla and the adrenal cortex. The adrenal medulla is associated with the release of the hormones cortisol and aldosterone. The cortex produces adrenaline and nor-adrenaline. Any disorder in the gland can affect its functioning and hormone release. When an inflammation occurs in the adrenal glands, it is called adrenalitis.

What Is Adrenalitis?

The infection of one or both the adrenal glands leads to adrenalitis, causing an inadequate production of adrenaline, noradrenaline, and cortisol. Cortisol is the hormone released in response to stress and regulates the inflammatory process, blood pressure, and blood sugar levels. Adrenaline maintains a balanced level of potassium and sodium in the blood, which in turn alters blood pressure levels. When these hormones are insufficient, the symptoms related to these conditions are produced.

What Are the Causes of Adrenalitis?

Adrenalitis can be divided into three types depending on the cause:

1. Xanthogranulomatous adrenalitis.

2. Autoimmune adrenalitis.

3. Hemorrhagic adrenalitis.

Of the three types, the most common cause is autoimmune adrenalitis. It accounts for 70 % of cases associated with adrenalitis.

What Are the Symptoms of Adrenalitis?

The symptoms vary depending on the cause and the severity of inflammation. The most common symptoms include:

• Weakness.

• Increased weight loss.

• Tiredness.

• Decreased appetite.

• Nausea.

• Vomiting.

• Diarrhea.

• Pain in the muscle and joints.

• Hypoglycemia (reduced blood sugar).

• Hyperpigmentation (darkening of the skin) of lips, gums, elbows, armpit, knuckles, and palm creases.

• Feeling of irritability and depression.

• A feeling of dizziness on standing suddenly after sitting for a long time.

What Is Xanthogranulomatous Adrenalitis?

Xanthogranulomatous adrenalitis is a rare inflammatory disease in the adrenal glands. The exact cause of the xanthogranulomatous inflammation is unknown. It can occur due to infection present for a long period of time and localized bleeding. The diagnosis for this condition is difficult since the aldosterone levels and the radiographic imaging by CT (computed tomography) scan showed normal results. The confirmation of the disease is mostly by histopathological examination. The histopathological examination involves collecting a portion of the cells or tissue, staining them, and a detailed examination under a microscope. It shows features of granulomatous inflammation, such as granulomas, foamy cells, and lymphocytes (a type of white blood cell).

What Is Autoimmune Adrenalitis?

Autoimmune adrenalitis is also called Addison’s disease. The exact cause of the condition is unknown. It can be due to the production of autoantibodies against the cells of the adrenal gland. Usually, the immune system attacks foreign bodies by producing antibodies against them. The immune system sometimes attacks the body’s cells, resulting in an autoimmune condition. In autoimmune adrenalitis, the immune system is provoked by a protein within the adrenal gland called 21-hydroxylase.

The protein plays an important role in releasing hormones from the gland. Since the protein triggers the immune system, it attacks the adrenal gland and, in particular, the outer surface of the gland, which is the adrenal cortex. So the hormones produced by the adrenal cortex, adrenaline and noradrenaline, are mainly affected. The lack of production of the hormones leads to hypoglycemia, hyponatremia (reduced sodium levels in the blood), muscle cramps, skin darkening, and other usual symptoms of adrenalitis. The doctor must be immediately consulted when any changes are noticed for early prevention and management of the disease.

What Is Hemorrhagic Adrenalitis?

Hemorrhagic adrenalitis refers to excessive bleeding within the adrenal glands leading to the failure of the gland to function properly. It is caused due to bacterial infection by meningococcus bacteria and other bacterial groups, such as Streptococcus, Staphylococcus, and Pseudomonas. The syndrome that is named after this condition is called the Waterhouse-Friderichsen syndrome. The person affected by this condition will experience rashes all over the body and the formation of blood clots.

A more severe form that is life-threatening is the development of septic shock and adrenal crisis. Septic shock occurs due to the extensive spread of infection in the body. An adrenal crisis occurs when insufficient hormones are available to produce from the gland leading to low blood pressure, increased heart rate, confusion, and coma. The treatment with antibiotics must be started as soon as possible to kill the bacteria and reduce the symptoms.

What Are the Investigations Done to Diagnose Adrenalitis?

The doctor will collect a detailed patient history regarding the symptoms and medical history regarding underlying medical illness or autoimmune condition. A thorough physical examination is performed to detect any signs of bleeding, infection, and hyperpigmentation. Finally, the doctor runs a series of tests to confirm the diagnosis of adrenalitis. For this, a blood sample is collected from the patient and sent for laboratory investigation. The various lab and imaging tests for adrenalitis are:

1. Aldosterone and Cortisol Level Test: A sample of blood is collected early in the morning and tested for aldosterone and cortisol levels. A level that is lower than the normal range indicates an abnormality with adrenal functioning.

2. Metabolic Levels: The blood levels of sugar, sodium, and potassium are tested to detect the presence of hypoglycemia.

3. Adrenocorticotropic Hormone (ACTH) Test: ACTH is the hormone responsible for releasing cortisol from the adrenal glands. Hence, in autoimmune adrenalitis, the levels of ACTH are increased.

4. Renin Levels: Like ACTH, renin is the hormone responsible for releasing aldosterone from the adrenal glands. The increase in renin levels is seen in cases of autoimmune adrenalitis.

5. ACTH Stimulation Test: It is a test to confirm a disorder within the adrenal glands. The doctor injects ACTH via the veins or muscles, and the response to the injection is recorded. If there is minimal or no response, it indicates adrenal gland dysfunction.

6. Anti-21 Hydroxylase Antibodies Screen: In autoimmune adrenalitis, the 21-hydroxylase is the protein attacked by the antibodies. Hence, the levels of the antibodies that are produced against the protein are tested to confirm the presence of autoimmune adrenalitis.

7. Blood Culture: A sample of cells or tissue is collected and visualized under a microscope to detect the presence of bacterial infection. This test helps to identify the hemorrhagic and xanthogranulomatous types of adrenalitis depending on the bacteria present.

8. Imaging Studies: A CT scan of the adrenal gland can help identify the cause and the type of adrenalitis to manage them appropriately.

What Is the Treatment for Adrenalitis?

The treatment for adrenalitis is mainly directed toward replenishing insufficient hormones produced by the adrenal glands. For adrenalitis that is caused due to an infection, appropriate antibiotic treatment is initiated. In addition, for all types of adrenalitis, steroid therapy is given to increase cortisol levels. Hydrocortisone and oral Prednisone are the medications prescribed to increase cortisol levels. Fludrocortisone, a medication to increase aldosterone secretion, helps to keep the plasma renin level within the normal range. The dose is calculated depending on each individual’s condition and given throughout the patient's lifetime.

Conclusion:

Adrenalitis is a condition that affects the adrenal gland function through an infection, hemorrhage, or the production of autoantibodies. The disease cannot be prevented completely. In certain cases, a lifelong supplementation of steroids is given to keep the symptoms under control. Autoimmune disease is the most common cause for the condition to develop, and the patient must be consulted as soon as the early signs of dysfunction are noticed. Complications such as adrenal crises can lead to unfavorable outcomes. Hence, the patient must always carry a steroid kit to overcome such a situation.