Which of the following are common manifestations of primary adrenal insufficiency (Addison's disease)? Select all that apply.

Choice A rationale Hypertension is not a manifestation of this disease; instead, patients typically exhibit hypotension. The deficiency of mineralocorticoids, specifically aldosterone, leads to decreased sodium reabsorption and increased water excretion by the kidneys. This results in a reduction in extracellular fluid volume and cardiac output. Normal blood pressure is maintained by these hormones; without them, patients often experience chronic low blood pressure and orthostatic changes, which can lead to syncope or dizziness. Choice B rationale Hyperpigmentation is a classic sign of primary adrenal insufficiency due to elevated levels of adrenocorticotropic hormone. When the adrenal glands fail, the pituitary gland increases production of this hormone to stimulate them. Since it shares a precursor with melanocyte-stimulating hormone, the excess levels lead to increased melanin production. This is most visible in skin creases, pressure points, and mucous membranes, giving the skin a bronzed appearance even in areas not exposed to sunlight. Choice C rationale Increased sweating is not a typical finding in this condition. In fact, patients may have decreased sweating or dry skin due to chronic dehydration and electrolyte imbalances. Excessive sweating is more commonly associated with conditions of sympathetic overactivity, such as hyperthyroidism or pheochromocytoma. In adrenal insufficiency, the metabolic rate is generally low, and the body's focus is on conserving what little fluid and salt remain, rather than expending them through thermoregulatory sweating. Choice D rationale Hyperkalemia occurs because of the lack of aldosterone, which normally promotes the excretion of potassium in exchange for sodium in the distal renal tubules. Without sufficient aldosterone, the kidneys retain potassium, leading to serum levels above the normal range of 3.5 to 5.0 mEq/L. High potassium can cause dangerous cardiac arrhythmias and muscle weakness. Monitoring electrolyte levels is critical in managing these patients to prevent life-threatening complications related to cardiac conduction abnormalities. Choice E rationale Weight loss is a common and often early manifestation of this disorder. It results from a combination of anorexia, nausea, and the loss of body fluids due to sodium wasting. Additionally, the deficiency of glucocorticoids like cortisol leads to impaired metabolism of carbohydrates, proteins, and fats, contributing to the depletion of body mass. Patients often report a significant and unintentional reduction in weight over weeks or months as the adrenal function progressively declines. Choice F rationale Bradycardia is not a standard sign of this condition; instead, patients often present with tachycardia. The rapid heart rate is a compensatory mechanism by the body to maintain cardiac output in the face of low blood volume and hypotension. While severe hyperkalemia can eventually cause heart blocks or slow rhythms, the initial and more common response to the fluid volume deficit in adrenal insufficiency is an increased heart rate to ensure tissue perfusion.