Primary adrenal insufficiency among Sri Lankan adults: A cross-sectional study in National Hospital Colombo, Sri Lanka

Background: Clinical, biochemical & radiological characteristics and aetiologies of primary adrenal insufficiency (PAI) among Sri Lankan adults are not known.
Aims: To describe the clinical features, aetiology, diagnostic and treatment outcomes of patients with PAI in Sri Lanka.
Methods: A cross-sectional study was conducted in Endocrine clinics of National Hospital of Sri Lanka. We screened prescription records to identify patients with PAI. Data was collected using a structured interviewer administered questionnaire and by reviewing clinic records, during their scheduled clinic visit.
Results: Forty patients were recruited (median age 38 (IQR 27-52), men 35%, 361 patient-years follow up). Adrenal tuberculosis was the aetiology in 10 / 40. Cause was unknown in 29 / 40, among whom 16 had an associated other organ autoimmune dysfunction. Delay in presentation, diagnosis and presentations with Addisonian crisis were less in patients who presented after 2010 compared to those before (9 vs 18 months, 6 vs 12 months and 5/12 vs 3/28 respectively).
Hyperpigmentation (39 / 40), weight loss (32/ 40) and postural lightheadedness (27 / 40) were the common manifestations. Adrenal atrophy and adrenal calcification were seen in 20/30 and 6/30 respectively. All patients were on hydro cortisone, 31 / 40 were on fludrocortisone and none were on androgen replacement. Incidence of Addisonian crisis was 7.5 per 100 patient-years: commonest cause was lapses in medication adherence (14 of 24 events).
Conclusion: Tuberculosis was the cause of PAI in 25% of adult patients. Aetiology in others is presently unknown. Delay in presentation and diagnosis has shortened over time. Addisonian crisis after diagnosis is commonly due to non-adherence.