# Situation: A 46-year-old man with primary adrenal insufficiency (Addison disease) is brought to the emergency department after 2 days of vomiting and diarrhea. He usually takes hydrocortisone 15 mg every morning and 5 mg every afternoon, and fludrocortisone 0.1 mg daily. He was treated for pulmonary tuberculosis 5 years ago. Which finding is expected in primary adrenal insufficiency and helps set it apart from the secondary (pituitary) form?

> source: MyMerci (mymerci.kr)  
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> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 46-year-old man with primary adrenal insufficiency (Addison disease) is brought to the emergency department after 2 days of vomiting and diarrhea. He usually takes hydrocortisone 15 mg every morning and 5 mg every afternoon, and fludrocortisone 0.1 mg daily. He was treated for pulmonary tuberculosis 5 years ago.

Which finding is expected in primary adrenal insufficiency and helps set it apart from the secondary (pituitary) form?

## 보기

1. Darkening of the skin and gums **✔ 정답**
2. Weight loss with poor appetite
3. Dizziness on standing up
4. Low blood glucose on fasting

**정답: 1**

## 해설

When the adrenal glands themselves fail, cortisol falls and the pituitary raises adrenocorticotropic hormone (ACTH); high ACTH stimulates skin pigment, darkening skin creases and gums. In secondary insufficiency ACTH is low, so hyperpigmentation does not occur. Weight loss, orthostatic dizziness, and hypoglycemia come from low cortisol and occur in both forms.

## 심화 해설

Core Pathophysiology

In primary adrenal insufficiency, the adrenal cortex itself is destroyed, so it cannot produce cortisol or aldosterone. The pituitary responds to the low cortisol by secreting more adrenocorticotropic hormone (ACTH). High circulating ACTH binds melanocortin receptors on melanocytes, increasing melanin production and causing hyperpigmentation of sun-exposed skin, palmar creases, buccal mucosa, and gums. In secondary adrenal insufficiency, the problem is in the pituitary or hypothalamus, so ACTH is low or absent; therefore, hyperpigmentation does not develop [1][2].

Why the Other Findings Do Not Differentiate

Weight loss with poor appetite, orthostatic dizziness, and fasting hypoglycemia all result from glucocorticoid deficiency itself. Because cortisol is low in both primary and secondary adrenal insufficiency, these manifestations appear in either form and cannot reliably separate the two [1][2]. Key point! Only the ACTH-dependent sign—hyperpigmentation—distinguishes primary from secondary disease.

Clinical Correlation With This Patient

This patient has a history of pulmonary tuberculosis treated 5 years ago. Tuberculosis can cause chronic granulomatous destruction of the adrenal glands, leading to primary adrenal insufficiency even years after successful antituberculous therapy [2]. The current presentation of vomiting, diarrhea, and likely dehydration places him at risk for adrenal crisis, which requires immediate glucocorticoid replacement [2]. His baseline regimen of hydrocortisone 15 mg in the morning and 5 mg in the afternoon, plus fludrocortisone 0.1 mg daily, reflects replacement of both glucocorticoid and mineralocorticoid—a pattern consistent with primary rather than secondary insufficiency.

| Feature | Primary Adrenal Insufficiency | Secondary Adrenal Insufficiency |
| --- | --- | --- |
| Site of defect | Adrenal cortex | Pituitary or hypothalamus |
| ACTH level | High | Low or normal |
| Hyperpigmentation | Present (skin, gums, creases) | Absent |
| Mineralocorticoid deficiency | Common (aldosterone low) | Rare (aldosterone usually preserved) |
| Weight loss, orthostatic dizziness, hypoglycemia | Present | Present |

Why Hyperpigmentation Is the Best Discriminator

The melanocyte-stimulating activity of ACTH is the only clinical feature that directly reflects the level of pituitary drive, making skin and mucosal darkening a specific marker of primary adrenal failure. In a case report of primary adrenal insufficiency, tongue and gingival discoloration accompanied unintentional weight loss and skin hyperpigmentation, confirming that mucosal pigmentation is a recognizable sign of elevated ACTH [1]. A pediatric case with post-tuberculosis adrenal damage likewise presented with shock, hypoglycemia, and hyperpigmentation, underscoring that the pigment change is a core diagnostic clue [2].

Watch out! Do not rely on weight loss, postural dizziness, or hypoglycemia to localize the lesion. These reflect cortisol deficiency and are shared by both primary and secondary forms. Key point! When a patient with known adrenal insufficiency develops vomiting and diarrhea, assess for adrenal crisis and anticipate the need for stress-dose steroids, regardless of whether the underlying cause is primary or secondary [2].References (research sources)

- [1]Woman with a Blackened Tongue: A Case Report.Case reportGirgis K, Toomasian C, Young T. (2026) · DOI: 10.5070/m5.52329

- [2]Post-Tuberculosis Adrenal Crisis in a Young Boy: A Case Report.Case reportHaleem A, Ashraf S, Tarique D, Zohair M, Singh A, Ayalew BD. (2025) · DOI: 10.1002/ccr3.71345

## 임상 시나리오

Distinguishing Primary vs Secondary Adrenal InsufficiencyHyperpigmentation as the key clinical clue
In primary adrenal insufficiency, the adrenal cortex fails, causing cortisol to fall and the pituitary to secrete high levels of ACTH. Elevated ACTH binds melanocortin receptors on melanocytes, producing hyperpigmentation of skin creases, gums, and sun-exposed areas.

In secondary adrenal insufficiency, the defect is in the pituitary or hypothalamus, so ACTH is low or absent. Without high ACTH, hyperpigmentation does not develop, making this sign the key discriminator between primary and secondary forms.

Findings such as weight loss, orthostatic dizziness, and fasting hypoglycemia arise from glucocorticoid deficiency itself and occur in both primary and secondary disease, so they cannot reliably separate the two.

CautionA history of tuberculosis can cause chronic adrenal destruction leading to primary adrenal insufficiency years later. Acute vomiting and diarrhea in such patients may precipitate adrenal crisis, requiring immediate glucocorticoid replacement.

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## 핵심 개념

- **Hyperpigmentation** — Darkening of skin creases, gums, and sun-exposed areas caused by high ACTH stimulating melanocytes in primary adrenal insufficiency
- **ACTH** — Adrenocorticotropic hormone; elevated in primary adrenal insufficiency due to loss of cortisol negative feedback, low in secondary form
- **Primary adrenal insufficiency** — Adrenal gland failure causing low cortisol and aldosterone with compensatory high ACTH; also called Addison disease
- **Secondary adrenal insufficiency** — Pituitary or hypothalamic dysfunction causing low ACTH and low cortisol, but aldosterone is typically preserved
- **Adrenal crisis** — Life-threatening acute decompensation of adrenal insufficiency triggered by infection, vomiting, or diarrhea requiring immediate glucocorticoid therapy

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