Adrenal Case Studies

Question 1

What are mineralocorticoids role in the body?

Answer 1

Regulate fluid volume and K+
~~Na retention
~~K+ excretion

Question 2

What is Cushing’s Syndrome?

Answer 2

Excess CORTISOL production

Becomes Cushing’s Dz if specifically caused by INCREASED ACTH secretion

Question 3

What are some screening tests for Cushing’s Syndrome?

Answer 3

Overnight Dex Suppression
~~1mg Dexamethasone (should suppress to < 2microgrm/dL)~~

24 hr urine free cortisol
~~50-75 microgrm in 24 hours~~

Late night salivary cortisol

Question 4

The ACTH and cortisol are both high in your PT; where do you suspect the “lesion” is?

What condition does this indicate?

Answer 4

Pituitary or ectopic ACTH

Cushing Syndrome

Question 5

If the ACTH level is <5 pg/mL which area is the lesion originating for the PT’s Cushing Syndrome?

Answer 5

Primary Adrenal (adenoma or cancerous) or iatrogenic origin (prolonged steroid use)

Question 6

If you attempt to Tx a PT’s recognized Cushing Syndrome (Hypercortisolism) which is iatrogenic in origin; what strategy would you take to manage this PT’s condition? Why?

Answer 6

Slow taper of corticosteroids (i.e. hydrocortisone)

Prevent Addisonian Crisis

Question 7

What is the clinical picture for Addison’s Disease? What is happening in the Dz pathophysiologically?

Answer 7

Autoimmune destruction of the adrenal gland

Increased tanning
Patches of pale skin (Vitiligo) 
Hx of HYPO-thyroidism
Orthostasis
Weight Loss
HYPO-glycemia --> low cortisol, low sugar

Question 8

What lab values or trends might you expect to see if you order labs for a PT with Addison’s?

Answer 8

Hyper-kalemia
Hypo-natremia
Low basal cortisol and aldosterone levels which fail to respond to ACTH
Early AM cortisol < 3 ug/dL

Question 9

What is the Tx for Addison’s Dz?

Answer 9

Hydrocortisone 20mg in AM; 10mg in afternoon

Fludrocortisone (Florinef) - 0.1mg/d w/ salt

Question 10

If you suspect a PT may be in adrenal crisis; how can you Dx and Tx them at the same time?

Answer 10

High Dose ACTH getting baseline ACTH and Cortisol

COVER PT w/ DEXAMETHASONE
~~Not measured in cortisol assay

IV saline w/ glucose

Question 11

What are some potential causes of primary Hyperaldosteronism?

Answer 11

Solitary adenoma
Bilateral idiopathic hyperplasia
Familial hyperaldosteronism
Cancer

Question 12

What would the clinical picture be of a presenting patient with primary hyperaldosteronism?

Answer 12

HTN (severe, resistant, early onset)

Normokalemia or HYPO-kalemia

Muscle weakness

Polyuria

No edema