02a: Adrenal Insufficiency, Cushing's

Question 1

Cortisol metabolic actions: (raises/lowers) blood glucose by stimulating which processes?

Answer 1

Raises;

Gluconeogenesis, lipolysis, protein catabolism

Question 2

Cortisol’s has effects on metabolism as well as which other physiological systems?

Answer 2

Circulatory (pressor effects) and immune (anti-inflamm)

Question 3

List the regulators of aldosterone secretion.

Answer 3

1. RAAS (A-II)
2. K
3. ACTH (less important)

Question 4

T/F: Cortisol secretion only controlled by ACTH

Answer 4

True

Question 5

Addison’s disease is (X) (excess/insufficiency).

Answer 5

X = primary adrenal

Insufficiency

Question 6

The difference between primary and secondary adrenal insufficiency is level of (X) hormone(s).

Answer 6

X = aldosterone and androgens (will be OK in secondary disease since ACTH is not only regulator for these)

Question 7

T/F: Cortisol levels are high in both primary and secondary adrenal insufficiency.

Answer 7

False - LOW in both

Question 8

List the symptoms of glucocorticoid (excess/deficiency) in Addison’s

Answer 8

Deficiency

Weight loss, nausea, fatigue, weakness, hypoglycemia

Question 9

List the symptoms of mineralocorticoid (excess/deficiency) in Addison’s

Answer 9

Deficiency

Postural hypotension, hyperkalemia, hyponatremia

Question 10

List the symptoms of ACTH (excess/deficiency) in Addison’s

Answer 10

Excess

Hyperpigmentation

Question 11

Both ACTH and (X) are cleaved from (Y) precursor protein. This explains which symptom in high ACTH state?

Answer 11

X = MSH (melanocyte stim hormone)
Y = POMC

Hyperpig

Question 12

List some infectious causes for primary adrenal insufficiency.

Answer 12

1. TB
2. HIV/AIDS
3. Systemic fungal

Question 13

Tapering off steroids is crucial because sudden withdrawal can cause (X) (excess/deficiency).

Answer 13

X = secondary adrenal insufficiency (lack of ACTH stimulus)

Question 14

You suspect adrenal insufficiency in patient. Which test(s) do you order?

Answer 14

Rapid Cortrosyn (ACTH) test (250 mcg ACTV IV)

Question 15

Rapid Cortrosyn test for adrenal insufficiency: (X) administered and which values measured?

Answer 15

X = ACTH (i.v.)

1. ACTH at level 0
2. Cortisol and aldosterone at 0, 30, 60 min

Question 16

Rapid Cortrosyn (ACTH) test: expected levels/response in normal patient…

Answer 16

1. Cortisol and aldosterone increase

2. ACTH in normal range

Question 17

Rapid Cortrosyn (ACTH) test: expected levels/response in Addison’s patient…

Answer 17

1. Cortisol and aldosterone low

2. ACTH super high

Question 18

Rapid Cortrosyn (ACTH) test: expected levels/response in secondary adrenal insufficiency patient…

Answer 18

1. Cortisol low (gland atrophy due to low ACTH); aldosterone normal
2. ACTH low *** key to distinguish from primary disease

Question 19

Adrenal insufficiency medication:

Answer 19

1. Glucocorticoid replacement (hydrocortisone/cortisone/prednisone)
2. Synthetic aldosterone (Florinef)
3. Maybe Androgen replacement for women?

Question 20

Adrenal insufficiency: patients must be educated about…

Answer 20

1. Steroid ID alert bracelet

2. Increase dose of meds if sick

Question 21

Most common cause of Cushing’s Syndrome:

Answer 21

High-dose steroid use

Question 22

(X)% of Cushing Syndrome is ACTH-dependent causes, such as:

Answer 22

X = 80

1. ACTH pituitary tumor (CUSHING DISEASE)
2. Ectopic ACTH (tumor)
3. CRH production (tumor, RARE)

Question 23

(X)% of Cushing syndrome is due to primary adrenal excess, caused by:

Answer 23

X = 20

1. Adrenal adenoma
2. Adrenal carcinoma (RARE)

Question 24

Cushing’s syndrome: (low/high) blood glucose, (low/high) BP.

Answer 24

High; high

Question 25

Pt has thin extremities, central obesity, easy bruising, purple stretch marks, and hypertension. You also notice hyperpigmentation of creases. What's at the top of your DDx?

Answer 25

Cushing's syndrome (due to ACTH excess - | hyperpigmentation)

Question 26

T/F: Cushing's due to adrenal adenoma is usually accompanied by excess aldosterone and maybe excess androgens.

Answer 26

False - usually PURE cortisol excess

Question 27

Pt with rapidly progressive muscle weakness, thin skin, hyperglycemia, and hypokalemia. Appears frail and reports recent weight loss. What are you worried about?

Answer 27

Adrenal carcinoma

Question 28

Screening test for Cushing's

Answer 28

24h urinary cortisol

Question 29

24h urinary cortisol test: false neg for cushing's may be due to..

Answer 29

Incomplete urine collection (be sure to measure Cr in sample to verify completeness)

Question 30

You suspect Cushing's in pt so you order 24h urine cortisol test. Levels come back high. What's the next step?

Answer 30

Measure ACTH (in urine)

Question 31

Cushing's: both urine cortisol and ACTH are high. What's the next step?

Answer 31

Measure inferior petrosal sinus ACTH levels before and after CRH injection; compare to antecubital ACTH (is ACTH coming from pituitary or ectopic?)

Question 32

If ACTH level in petrosal sinuses is (X)-fold greater than antecubital level, where is the tumor?

Answer 32

X = 3 Pituitary

Question 33

Rx for Cushing's syndrome from adrenal adenoma

Answer 33

Surg

Question 34

Rx for Cushing's disease

Answer 34

1. Resect pit tumor (may recur) 2. Irradiation 3. Adrenalectomy, meds?