Adrenal and Pituitary Disease Lecture Flashcards
What are the symptoms and signs that may make you suspect hypoadrenalism?
- Weight loss and lethargy
- Postural hypotension
- Nausea, vomiting
- Hyponatraemia +/- hyperkalaemia
- Addisonian crisis
What are some symptoms/signs of Addison’s Disease?
- Mucous membrane pigmentation
- Skin pigmentation (extensors, knuckles esp)
- Freckling
- Vertigo
- Pigment accentuation at nipples
- Pigment concentration in skin creases or scars
- Weight loss
- Anorexia
- Vomiting + diarrhoea
- Muscular weakness
- Postural hypotension
Why do you have changes to pigmentation in addison’s disease?
Increased ACTH causes increases melanocyte stimulating hormone
What are the clinical findings of an adrenal crisis?
- Dehydration, hypotension or shock out of proportion to illness
- N + V
- Weight loss
- Acute abdomen
- Unexplained hypogycaemia
- Unexplained fever
- Hyponatraemia, Hyperkalaemia, hypercalcaemia, eosinophilia, azotemia (urea + creatinine)
- Hyperpigmentation or vitiligo
- Other AI issues
What should low sodium and high potassium always make you think of?
Primary hyperadrenalism
What investigations should you do for hypoadrenalism?
Serum cortisol level: (random vs morning)
- Pulsatile secretion and diurnal variation makes interpretation difficult
- Time of day dependent
- Wide reference range (for morning cortisol level)
Stimulation testing:
- Short synacthen test (serum cortisol O’, 30’ and 60’ after synthetic ACTH 260 IM)
If patients are on exogenous glucocorticoids you can just diagnose clinically
How can you differentiate primary adrenal insufficiency from secondary or tertiary adrenal insufficiency?
The Synacthen Test/ACTH Stimulation Test
- ACTH should increase cortisol
If low cortisol = primary problem
Normal or increased cortisol= secondary or tertiary problem
Check plasma ACTH also
What other deficiencies should you investigate when you suspect PRIMARY adrenal insufficiency?
Mineralocorticoid deficiency!
- Hyperkalaemia
- Aldosterone and renin
What antibodies should you check for if someone has PRIMARY adrenal insufficiency?
Adrenal
Ovarian
Thyroid
How quickly can you withdraw glucocorticoids safely?
You can get clinically significant suppression after 2 weeks of glucocorticoids over supraphysiological doses
Reduce gradually!! Esp once at 7.5mg/day of pred
If someone with Addison’s disease is admitted with appendicitis- what should you consider in the management of them?
IMMEDIATE: the acute stress of the illness means they probs need more help
- IV hydration
- IV hydrocortisone 100mg
- When tolerating oral intake, commence on oral replacement and then taper down
LONG TERM:
- Need to be monitored to ensure replacement was enough
- Weight
- Cushingoid features
- Electrolytes
If someone presents with hypopituitarism presents with an acute illness what are your management priorities?
- Glucocorticoid assessment and replacement (IMPORTANT- this is life threatening so should be immediate)
- Then give thyroxine after
- Others (but not life threatening): gonadal hormones, growth hormone in children
What are the features of cushing’s syndrome?
- Depression/psychoses
- Mood alterations
- Cataracts
- Moon face
- Hirsutism
- HTN with secondary cardiomegaly
- Elevated glucose
- Muscle weakness
- Osteoporosis
- Thin skin
- Proximal myopathy
- Oligomenorrhea/amenorrhea
- Abdominal striae
What are some causes of Cushing’s?
ACTH Dependent Cushing’s Syndrome:
- Cushing disease
- Ectopic ACTH syndrome
- Ectopic CRH syndrome
ACTH Independent Cushing’s Syndrome:
- Adrenal adenoma
- Adrenal carcinoma
- Micro/Macronodular hyperplasia
Pseudo-Cushing’s Syndrome:
- MDD
- Alcoholism
How do you diagnose Cushing’s?
First:
- Increased urinary free cortisol (3 24hr collections)
- Lack of cortisol suppression after low-dose dexamethasone testing
- Increase Late evening salivary cortisol
Then: consider the ACTH vs not ACTH causes
- ACTH
- CRH test
- 8mg dex
- CT/MRI adrenal
- MRI pituitary
- BIPSS
What hormones are made by the adrenal gland?
