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HIPOADRENOCORTICISMO
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”SINDROME DE ADISSON”
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ENDOCRINOLOGIA ____________________________________
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• MSC. GUSTAVO DITTRICH ____________________________________
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DEFINIÇÃO
Diminuição da secreção adrenocortical
(glicocorticoides e mineralocorticoides)
Cortisol
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X
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Retém Na+ ____________________________________
Aldosterona ____________________________________
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Elimina K+ ____________________________________
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CAUSAS
»Hipoadrenocorticismo primário
»Imunomediado
»Idiopático
»Iatrogênico (mitotano, trilostano)
»Hipoadrenocorticismo secundário
»Neoplasia em hipófise
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Mais comum! ____________________________________
90% ____________________________________
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SINAIS CLÍNICOS ____________________________________
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»Apatia, fraqueza ____________________________________
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»Anorexia ____________________________________
»PU/PD ____________________________________

»Êmese e diarreia ↓Na+ ____________________________________

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»Tremores ____________________________________
»Emagrecimento ____________________________________
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»Desidratação
↑K+ ____________________________________
»Hipotensão ____________________________________
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»Bradicardia ____________________________________
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DIAGNÓSTICO
»Resenha, anamnese, exame físico
»Exames laboratoriais
»Hemograma: linfocitose, eosionofilia
»Bioquímica sérica
» Azotemia pré-renal
» Hiponatremia e hipercalemia
» Na/K < 27!!!
» Hipoglicemia
»Urinálise: baixa densidade urinária
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DIAGNÓSTICO
»Outros exames
»Eletrocardiografia: bradiarritmia (↑K+)
»Radiografia torácica: microcardia
»Ultrassonografia: ↓ adrenais
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DIAGNÓSTICO ____________________________________
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»Função adrenal ____________________________________
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»Cortisol após teste de estimulação ____________________________________
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com ACTH ____________________________________
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0 h 1 h ____________________________________
Cortisol basal Cortisol 1h após ____________________________________
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TRATAMENTO
»Crise Addisoniana (emergência!)
»Fluidoterapia sem potássio
»Solução fisiológica (NaCl 0,9%)
»Glico e mineralocorticoide
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TRATAMENTO ____________________________________
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Composto Potência Potência
Glicocorticóide Mineralocorticóide ____________________________________
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Ação Rápida ____________________________________
Hidrocortisona 1,0 1,0 ____________________________________
Cortisona 0,8 0,8 ____________________________________
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Ação Intermediária
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Prednisolona 4,0 0,8 ____________________________________
Prednisona 4,0 0,8 ____________________________________
Metilprednisolona 5,0 Mínima ____________________________________
Triancinolona 5,0 Zero ____________________________________
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Ação Lenta ____________________________________
Dexametasona 30 Mínima ____________________________________
Betametasona 30 Indeterminada ____________________________________

TRATAMENTO
»Crise Addisoniana (emergência!)
»Fluidoterapia sem potássio
» Solução fisiológica (NaCl 0,9%)
»Glico e mineralocorticoide
» Hidrocortisona
» Dexametasona
»Tratamento sintomático
» Ranitidina, ondansetrona, dipirona...
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TRATAMENTO
»Manutenção (em casa)
»Fludrocortisona
» 10 a 30 μg/Kg VO, 24 hrs
»Prednisona
» 0,2 a 0,5 mg/Kg VO, 24 hrs
»Desoxicorticosterona (DOCP)
» 2,2 mg/Kg IM, 25 dias
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DISCUSSÃO DE CASO CLÍNICO ____________________________________
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RESENHA
» Cão, fêmea, castrada, 8 anos, SRD, 8 Kg
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ANAMNESE ____________________________________
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» Apatia e prostração ____________________________________
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» Emagrecimento (1-2 Kg em 7 dias!) ____________________________________
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» Hiporexia ____________________________________
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» Tremores ____________________________________
» PU/PD ____________________________________
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» Nega êmese, diarreia, tosse, espirro, secreção ____________________________________
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ocular ou nasal. ____________________________________
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EXAME FÍSICO
§ Mucosas normocoradas
§ TPC 3 segundos
§ Aumento do turgor de pele
§ Ressecamento de mucosa
§ Enofltamia discreta
§ Sopro grau III/VI foco mitral
§ Palpação abdominal: sem dor, ausência de ____________________________________
organomegalia
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Desidratação ____________________________________
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moderada ____________________________________
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PATOLOGIA CLÍNICA ____________________________________
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» Hemograma - Eritrograma, PP e plaquetas ____________________________________
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Parâmetros Valor Referência
Parâmetros Valor Referência ____________________________________
Eritrócitos 7,31 milhões/mm3 5,5 – 8,5 milhões/mm3 ____________________________________
Eritrócitos 7,31 milhões/mm3 5,5 – 8,5 milhões/mm3 ____________________________________
Hemoglobina 15,1 g/dL 12 – 18 g/dL ____________________________________
Hemoglobina 15,1 g/dL 12 – 18 g/dL ____________________________________
Hematócrito 48% 37-47% ____________________________________
Hematócrito 48% 37-47%
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VGM 65,66 fL 60-77 fL
VGM 65,66 fL 60-77 fL ____________________________________
CHGM 32,46% 32-36% ____________________________________
CHGM 32,46% 32-36% ____________________________________
Proteína plasmática 10,6 g/dL 6-8 g/dL ____________________________________
Proteína plasmática 10,6 g/dL 6-8 g/dL
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Plaquetas 404.000 200.000 – 600.000 ____________________________________
Plaquetas 404.000 200.000 – 600.000
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Desidratação
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PATOLOGIA CLÍNICA ____________________________________
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» Hemograma - Leucograma ____________________________________
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Parâmetros Valor Referência
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Leucócitos totais 9.800 6.000 – 17.000 ____________________________________
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Neutrófilos segmentados 5.390 3.000 – 11.500 ____________________________________
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Neutrófilos bastonetes 0 0 – 300 ____________________________________
Metamielócitos 0 0 ____________________________________
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Linfócitos 2.744 1.000 – 4.800 ____________________________________
Eosinófilos 588 100 – 1.250 ____________________________________
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Monócitos 1.078 150 – 1.350 ____________________________________
Basófilos 0 Raros ____________________________________
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Nada digno de nota
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BIOQUIMICA SÉRICA ____________________________________
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Parâmetro Valor Referência ____________________________________
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Albumina 2,74 g/dL 2,6 – 3,3 g/dL ____________________________________
ALT 34 UI 0 – 102 UI ____________________________________
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Creatinina 2,07 mg/dL 0,5 – 1,5 mg/dL
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Fosfatase Alcalina 108 UI 20 – 156 UI ____________________________________
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Glicemia 88 mg/dL 70-110 mg/dL ____________________________________
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Ureia 69 mg/dL 20 – 60 mg/dL
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Sódio (Na+) 144 mmol/L 145 – 151 mmol/L ____________________________________
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Potássio (K+) 6,8 mmol/L 3,9 – 5,1 mmol/L ____________________________________
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Cloro (Cl-) 110 mg/dL 109 – 122 mg/dL ____________________________________
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Azotemia Hiponatremia Hipercalemia
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URINALISE ____________________________________
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Exame físico Valor Exame Valor ____________________________________
químico ____________________________________
Cor Amarelo claro
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Glicose Negativo
Aspecto Turvo ____________________________________
Corpos ____________________________________
Volume 12 mL Negativo
cetônicos ____________________________________
Densidade 1,018 pH 6,0 ____________________________________
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Sedimentoscopia Valor Sangue Negativo ____________________________________
Céls. descamação do Bilirrubina Negativo ____________________________________
Negativo
trato urinário Proteína Negativo ____________________________________
Bactérias Negativo ____________________________________

Leucócitos Negativo
Diminuição da ____________________________________
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Hialinos raros e densidade ____________________________________
Cilindros ____________________________________
Granulosos raros
urinária ____________________________________
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IMAGEM ____________________________________
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» Ultrassonografia abdominal ____________________________________
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» Rins e bexiga ____________________________________
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» Fígado e baço ____________________________________
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Sem ____________________________________
» Estômago, alças intestinais ____________________________________
alterações ____________________________________
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» Adrenais e pâncreas ____________________________________
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» Linfonodos ____________________________________
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IMAGEM
» Ultrassonografia abdominal
» - Vesícula biliar: estrutura ecogênica em lume,
margens irregulares, aderida a parede, 0,7 cm
de diâmetro
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IMAGEM
»Ecocardiografia
» DIAGNÓSTICO
» - Endocardiose de mitral com insuficiência
moderada.
» - Hipocinesia miocárdica difusa leve.
» OBSERVAÇÕES: A diminuição da contratilidade
pode estar associada a condições sistêmicas que
liberem citocinas, reduzindo a contratilidade
miocárdica.
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IMAGEM ____________________________________
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PATOLOGIA CLÍNICA ____________________________________
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» Bioquímica sérica ____________________________________
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» Na = 144 ____________________________________
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» K = 6,8 ____________________________________
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» Relação Na:K (Na/K) = 144/6,8 = 21 ____________________________________
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Normal: Na/K > 27 ____________________________________
Hipoadreno ____________________________________

corticismo Anormal: Na/K < 27 ____________________________________

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Sugestivo: Na/K < 17 ____________________________________
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DOSAGEM HORMONAL
Teste de estimulação com ACTH
0 hrs
Coleta de sangue para dosagem de
cortisol e aplicação de ACTH
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1 hr ____________________________________
Coleta de sangue para ____________________________________
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dosagem de cortisol
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DOSAGEM HORMONAL ____________________________________
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Hipotálamo ____________________________________
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CRH ____________________________________
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Feedback - ____________________________________
Hipófise ____________________________________
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ACTH ____________________________________
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Adrenal ____________________________________
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CORTISOL
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TESTE DE ESTIMULAÇÃO ____________________________________
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DIAGNÓSTICO DEFINITIVO ____________________________________
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»Hipoadrenocorticismo ____________________________________
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»ou
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»Síndrome de Addison ____________________________________
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TRATAMENTO ____________________________________
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» Emergencial: ____________________________________
→ Fluidoterapia: ____________________________________
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- NaCl 0,9%: correção da desidratação + ____________________________________
manutenção ____________________________________
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→ Corticosteroide de ação rápida ____________________________________
- Hidrocortisona: 0,5 mg/Kg/h (infusão ____________________________________
contínua) ou 5 a 20 mg/Kg (a cada 6 hrs) ____________________________________
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TRATAMENTO ____________________________________
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Composto Potência Potência ____________________________________
Glicocorticóide Mineralocorticóide ____________________________________
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Ação Rápida
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Hidrocortisona 1,0 1,0 ____________________________________
Cortisona 0,8 0,8 ____________________________________
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Ação Intermediária ____________________________________
Prednisolona 4,0 0,8 ____________________________________
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Prednisona 4,0 0,8 ____________________________________
Metilprednisolona 5,0 Mínima ____________________________________
Triancinolona 5,0 Zero ____________________________________
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Ação Lenta ____________________________________
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Dexametasona 30 Mínima
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TRATAMENTO ____________________________________
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TRATAMENTO ____________________________________
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» Manutenção ____________________________________
» Fludrocortisona ____________________________________
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» 10 a 30 μg/Kg VO , 24 hrs ____________________________________
» Prednisona ____________________________________
» 0,2 a 0,5 mg/Kg VO , 24 hrs ____________________________________
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EVOLUÇÃO ____________________________________
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PROGNÓSTICO ____________________________________
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BOM!
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