Characteristics and Challenges of Primary Adrenal Insufficiency in Africa: A Review of the Literature

Table 1

Summary of available cohort studies investigating the prevalence and aetiology of primary adrenal insufficiency in Africa under various clinical scenarios.

Authors (year)	Number	Sex : F : M	Country	Findings and context	Ref
Ross et al. 2010	148	91 : 57	RSA	The cohort of PAI patients (based on 250 μg tetracosactide and cortisol cutoff of <550 nmol/L associated with an elevated plasma ACTH (50%) had an autoimmune aetiology, and 65% of them were of European descent.	[11]
Ross et al. 2013	148	91 : 57	RSA	In the PAI cohort, in which the most common signs were hyperpigmentation (76%), nausea and vomiting in more than 40%.	[12]
Fourati et al. 2012	60	44 : 16	Tunisia	In APS patients, of whom 20 were found to have Addison’s disease in varying association with other autoimmune conditions, e.g., T1D (73.3%), POF (3.3%), and AITD (91.7%).	[34]
Kallabi et al. 2016	26	14 : 12	Tunisia	A genetic study of Allgrove syndrome revealed a primary homozygous mutation (c.1331 + 1G > A) in 25 patients and R286X mutation in one patient. PAI was found in all patients on clinical grounds and an elevated plasma ACTH and reduced random cortisol concentrations.	[37]
Broodryk. 2010	73	49 : 24	RSA	Sputum-positive TB patients underwent the tetracosactide test; 5 had hypoadrenalism defined by serum cortisol <500 nmol/l	[67]
Odeniyi et al. 2013	43	20 : 23	Nigeria	HIV-positive patients underwent the tetracosactide test; 15 (34.8%) had hypoadrenalism defined as serum cortisol <380.2 nmol/l.	[90]
Odeniyi et al. 2017	44	No mention	Nigeria	Two groups underwent the tetracosactide test; one group had TB alone, whereas the other group had TB & HIV. 14 (31.1%) and 2 (5%) of the former and latter groups, respectively, had hypoadrenalism defined as cortisol <380.2 nmol/l.	[66]
Mugusi et al. 1990	50	No mention	Tanzania	Chronic TB patients underwent the tetracosactide test; 16 (32%) had hypoadrenalism by stimulated plasma cortisol <600 mmol/l.	[91]
Ekpebegh et al. 2011	66	39 : 27	RSA	HIV-positive patients underwent the tetracosactide test; hypoadrenalism (based on cortisol cutoff of <400 nmol/L) was diagnosed in 27%.	[72]
Musa et al. 2021	80	31 : 49	Sudan	422 suspected with suggestive symptoms were screened using the 250 mcg tetracosactide test, and 80 met the criteria. The morning cortisol level was <27.6 nmol/L in 70 and borderline 27.7 nmol/L–331.1 nmol/L in 10 patients with elevated ACTH levels. Aetiology ranged from Allgrove syndrome (29/80), APS (9/80), ALD (7/80), bilateral haemorrhage (1/80), and unspecified (34/80).	[81]
Odeniyi et al. 2011	44 : 70	21 : 23 35 : 35	Nigeria	44 sputum-positive TB patients and 70 controls underwent the tetracosactide test (hypoadrenalism defined as 30 minutes cortisol <380 nmol/L or increment from baseline of <158 nmol/L); of the 44 TB patients, 5 males and 5 females met the hypoadrenalism criteria.	[92]
Mabuza et al. 2020	75	32 : 43	RSA	TB patients underwent the 1 mcg tetracosactide test: 28 (37.3%) met the hypoadrenalism criteria of 30 minutes serum cortisol of <550 nmol/L.	[93]
Akase et al. 2019	350	178 : 172	Nigeria	HIV-positive patients on ART underwent the 1 mcg tetracosactide test: 57 (16.3%) met the 30 minutes criteria of serum cortisol <500 nmol/L.	[94]

PAI: primary adrenal insufficiency; APS: antiphospholipid syndrome; ALD: adrenoleukodystrophy; TB: tuberculosis; HIV: human immunodeficiency virus: ART: antiretroviral therapy; TID: type 1 diabetes; POF: premature ovarian failure; AITD: autoimmune thyroid disease; RSA: Republic of South Africa.