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Operational implications
A person who is required to void urine frequently and to drink large amounts of fluid would obviously be
at a disadvantage in a control situation. However, if the diabetes insipidus is controlled adequately, there
should be no hazard.
Aeromedical considerations
Recertification in any category should be considered if the individual is adequately treated under the
supervision of an endocrinologist. Chlorpropamide is unacceptable for aviation duties due to the risk of
hypoglycaemia.
7 Sheehan’s syndrome: necrosis of the anterior pituitary gland as a result of severe post-partum haemorrhage and
shock. Named after Harold Leeming Sheehan, English pathologist (1900-1988)
ICAO Preliminary Unedited Version — March 2010 III-4-11
THE ADRENAL GLANDS
The adrenal glands are situated in the upper poles of the kidney. Anatomically and functionally they can
be divided into outer cortex and inner medulla. The outer cortex produces aldosterone, cortisol and some
androgens. The medulla is responsible for any adrenaline secretion in response to distress. The enzymatic
conversion of nor-adrenaline to adrenaline is cortisol dependent.
DISEASES OF THE ADRENAL CORTEX
Addison’s disease8 (primary hypoadrenalism)
In this condition the adrenal cortex fails to produce or produces inadequate amounts of normal hormones.
Initially this was described by Addison as the result of caseating tuberculosis but it can also be caused by
autoimmune induced destruction of the adrenal cortex.
Signs and symptoms
These include:
a) lassitude, somnolence, depression
b) hypotension, hyperkalaemia, salt and water loss, hypoglycaemia, hypercalcaemia
c) associated vitiligo, myxoedema or pernicious anaemia
d) ECG changes secondary to raised potassium (tall peaked T-wave)
If the onset is slow, the diagnosis may be missed and other labels attached such as depression or anorexia
nervosa.
Investigations
A high index of suspicion is a useful aid to early diagnosis. If the patient presents hypotensive and
severely ill, i.e. in addisonian crisis, blood should be taken for electrolytes and cortisol assay and
treatment initiated forthwith. If the patient is not critically ill, the investigation of choice is the short
acting synacthen (tetracosactrin) test: in a normal person, i.m. injection of 250 μg synacthen will produce
a rise in plasma cortisol 45 minutes later of approximately 550 nmol/L or more; values less than that are
consistent with primary or secondary hypoadrenalism. Proof of primary adrenal insufficiency is
measurement of ACTH levels which are extremely high; a long acting synacthen test over a 4-5 day
period may also confirm the diagnosis. Cortisol response only occurs in secondary adrenal failure. The
aetiology can be identified by tests for autoantibodies, x-ray of the abdomen or CT-scanning showing
adrenal calcification.
Management
Long term management is by hydrocortisone (cortisol) 20 mg in the morning and 10 mg in the evening.
The dose may be adjusted by measuring cortisols throughout the day if problems develop. Similar clinical
effects can be expected from the following doses of steroids: cortisone acetate 25 mg, prednisolone 5 mg
and dexamethasone 0.5 mg.
8 Addison’s disease: chronic adrenocortical insufficiency. After Thomas Addison, English physician (1793-1860).
ICAO Preliminary Unedited Version — March 2010 III-4-12
Mineralocorticoid may not be required in some patients as the zona glomerulosa of the cortex sometimes
is spared. If replacement is required, fludrocortisone 0.05-0.2 mg in a single dose is used. Ideally the
optimum dose is that which maintains renin levels within normal limits. This assay is expensive and not
universally available. It is usual practice to monitor blood pressure and electrolyte levels.
Patients with adrenal insufficiency should carry a card or a Medicalert bracelet or necklace with details of
the diagnosis and treatment. They must be advised to double or triple the dose of hydrocortisone during
injury or febrile illness. Some physicians suggest they should be given ampoules of glucocorticoid for
self-injection or glucocorticoid suppositories to be used in the case of vomiting.
Operational implications
An individual receiving adequate substitution therapy should have no problems in a command situation.
However, both the individual and his colleague should be aware of the possibility of stress-induced
relapse.
Aeromedical considerations
The applicant may be certificated in any category with a specific proviso that therapy must be supervised
by an endocrinologist with semi-annual review.
Conn’s syndrome9
This syndrome is an extremely rare condition consisting of adenoma, carcinoma or hyperplasia of the
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Manual of Civil Aviation Medicine 1(127)
