{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,29]],"date-time":"2025-08-29T10:45:27Z","timestamp":1756464327677,"version":"3.40.5"},"reference-count":26,"publisher":"Public Library of Science (PLoS)","issue":"11","license":[{"start":{"date-parts":[[2020,11,5]],"date-time":"2020-11-05T00:00:00Z","timestamp":1604534400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\"><jats:title>Objective<\/jats:title><jats:p>We wished to determine the prevalence, etiology, presentation, and available management strategies for primary adrenal insufficiency (PAI) in South Africa (SA), hypothesizing a prevalence greater than the described 3.1 per million. There is great inequity in healthcare allocation, as two parallel healthcare systems exist, potentially modifying PAI patients\u2019 clinical profiles, private being better resourced than public healthcare.<\/jats:p><\/jats:sec><jats:sec id=\"sec002\"><jats:title>Methods<\/jats:title><jats:p>An online survey of physicians\u2019 experience relating to PAI.<\/jats:p><\/jats:sec><jats:sec id=\"sec003\"><jats:title>Results<\/jats:title><jats:p>The physicians were managing 811 patients, equal to a prevalence of 14.2 per million. Likely causes of PAI in public\/ academic vs private settings included: AIDS-related [304 (44.8%) vs 5 (3.8%);<jats:italic>p<\/jats:italic>&lt;0.001], tuberculosis [288 (42.5%) vs 8 (6.0%);<jats:italic>p<\/jats:italic>&lt;0.001], autoimmune disease [50 (7.4%) vs 88 (66.2%);<jats:italic>p<\/jats:italic>&lt;0.001], malignancy [27 (4.0%) vs 7 (5.3%);<jats:italic>p<\/jats:italic>= 0.500], genetic including adrenoleukodystrophy (ALD) [5 (0.7%) vs 16 (12.0%);<jats:italic>p<\/jats:italic>&lt;0.001], respectively. Overall, more patients presented with nausea [101 (74.3%) and vomiting 89 (65.9%), than diarrhoea 76 (58.9%);<jats:italic>p<\/jats:italic>= 0.008 and 126 (15.5%) in adrenal crisis. Features suggestive of a crisis were hypoglycaemia [40 (78.4%) vs 42 (48.8%);<jats:italic>p<\/jats:italic>= 0.001], shock [36 (67.9%) vs 31(36.9%);<jats:italic>p<\/jats:italic>&lt;0.001], and loss of consciousness [25 (52.1%) vs 27 (32.9%);<jats:italic>p<\/jats:italic>= 0.031]. Greater unavailability of antibody testing in the public vs. the private sector [32 (66.7%) vs 30 (32.1%);<jats:italic>p<\/jats:italic>= 0.001], [serum-ACTH 25 (52.1%) vs 16 (19.5%);<jats:italic>p<\/jats:italic>&lt;0.001] and glucocorticoids were [26 (54.2%) vs 33 (40.2%);<jats:italic>p<\/jats:italic>= 0.015]. Many patients, 389(66.7%) were not using identification, indicating that they need steroids in an emergency.<\/jats:p><\/jats:sec><jats:sec id=\"sec004\"><jats:title>Conclusion<\/jats:title><jats:p>A survey of South African physicians suggests a higher prevalence than previously reported. Patients presented with typical symptoms, and 15.5% presented in adrenal crisis. Significant disparities in the availability of physicians\u2019 expertise, diagnostic resources, and management options were noted in the public versus private settings. Greater awareness among health practitioners to timeously diagnose PAI is required to prevent a life-threatening outcome.<\/jats:p><\/jats:sec>","DOI":"10.1371\/journal.pone.0241845","type":"journal-article","created":{"date-parts":[[2020,11,5]],"date-time":"2020-11-05T18:46:29Z","timestamp":1604601989000},"page":"e0241845","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":5,"title":["Tiered healthcare in South Africa exposes deficiencies in management and more patients with infectious etiology of primary adrenal insufficiency"],"prefix":"10.1371","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5944-8350","authenticated-orcid":true,"given":"Thabiso Rafaki Petrus","family":"Mofokeng","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5283-2085","authenticated-orcid":true,"given":"Kwazi Celani Zwakele","family":"Ndlovu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Salem A.","family":"Beshyah","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ian L.","family":"Ross","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2020,11,5]]},"reference":[{"issue":"5","key":"pone.0241845.ref001","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1530\/EC-20-0129","article-title":"Significant barriers to diagnosis and management of adrenal insufficiency in Africa","volume":"9","author":"TR Mofokeng","year":"2020","journal-title":"Endocrine Connections"},{"issue":"1","key":"pone.0241845.ref002","doi-asserted-by":"crossref","first-page":"e53526","DOI":"10.1371\/journal.pone.0053526","article-title":"Addison\u2019s disease symptoms\u2014a cross sectional study in urban South Africa","volume":"8","author":"IL Ross","year":"2013","journal-title":"PLoS One"},{"key":"pone.0241845.ref003","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1159\/000321239","volume-title":"Pediatric Adrenal Diseases","author":"C Betterle","year":"2011"},{"issue":"6","key":"pone.0241845.ref004","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1046\/j.1365-2265.2002.t01-1-01552.x","article-title":"High prevalence and increasing incidence of Addison\u2019s disease in western Norway","volume":"56","author":"K L\u00f8v\u00e5s","year":"2002","journal-title":"Clinical endocrinology"},{"issue":"9","key":"pone.0241845.ref005","first-page":"3163","article-title":"Etiological diagnosis of primary adrenal insufficiency using an original flowchart of immune and biochemical markers","volume":"83","author":"S Laureti","year":"1998","journal-title":"The Journal of Clinical Endocrinology & Metabolism"},{"issue":"9372","key":"pone.0241845.ref006","doi-asserted-by":"crossref","first-page":"1881","DOI":"10.1016\/S0140-6736(03)13492-7","article-title":"Adrenal insufficiency","volume":"361","author":"W Arlt","year":"2003","journal-title":"The Lancet"},{"issue":"2","key":"pone.0241845.ref007","first-page":"85","article-title":"Addison\u2019s disease: a case report","volume":"2","author":"C Alebiosu","year":"2003","journal-title":"Annals of African Medicine"},{"key":"pone.0241845.ref008","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1016\/j.lungcan.2016.12.010","article-title":"Is clarithromycin a potential treatment for cachexia in people with lung cancer? 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