Adrenal Cases Flashcards
Where is cortisol made?
Zona fasciculata
31 yo presents with fatigue and vomiting, acutely unwell for few days
Na: 125, K: 6.5, U 10, Glucose 2.9mM.
FT4 < 5nM TSH > 50mU/l
What does this TSH suggest?
Primary Hypothyroidism
Na: 125, K: 6.5, U 10, Glucose 2.9mM.
FT4 < 5nM TSH > 50mU/l
Other than the thyroid disease, what other abnormalities are seen here?
Hyponatraemia
Hyperkalaemia
Hypoglycaemia
Na: 125, K: 6.5, U 10, Glucose 2.9mM.
FT4 < 5nM TSH > 50mU/l
What are these electrolyte abnormalities suggestive of (aside from the TSH)?
Hyponatraemia, hyperkalaemia
Deficiency of mineralocorticoid.
Hypoglycaemia
Deficiency of glucocorticoid.
Which endocrine disease typically presents with hyponatraemia, hyperkalaemia and hypoglycaemia?
Addisons disease
What is Schmidt’s syndrome (polyglandular autoimmune syndrome type II)?
Addison’s disease and primary hypothyroidism occur together more commonly than by chance alone.
What is the test for Addisons?
Short Synacthen test
How do you carry out the short synacthen test?
Measure cortisol + ACTH at start of test
Administer 250 micrograms synthetic ACTH by IM injection.
Check cortisol at 30 and 60 minutes.
A patient’s short synacthen test results show this:
ACTH > 100 ng/dl
Cortisol < 10 nM
Check cortisol at 30 and 60 minutes.
Both times, cortisol < 10 nM
What is the diagnosis?
Addisons disease
A 32 year old presents with hypertension.
He is noted to have an adrenal mass.
There are three possible differentials:
What is the differential diagnosis ?
Phaeochromocytomas
Conn’s syndrome
Cushing’s syndrome
Further investigations reveal that he has high levels of urinary catecholamines.
What urgent drug treatment is required?
What is the cure?
Urgent alpha blockade with phenoxybenzamine.
Add beta blockade.
Finally arrange surgery.
What is a phaeochromocytoma?
Adrenal medullary tumour that secretes adrenaline, and can cause severe hypertension, arrhythmias and death.
Hypertensive 33 year old.
Na 147, K 2.8, U 4.0. Glucose 4.0 mM
Plasma aldosterone raised.
Plasma renin suppressed.
What is the diagnosis ?
Conn’s syndrome
34 year old obese woman with type 2 diabetes, presents with hypertension and bruising.
Na: 146, K: 2.9, U 4.0, Glucose 14.0
Aldosterone <75 (low). Renin low
What is the diagnosis?
Cushing’s Syndrome
What is the test for Cushing’s?
9am cortisol
12 midnight cortisol
Which dynamic test is used for cushings?
Dexamethasone suppression test- Normal would cause cortisol suppression
What are the causes of cushing’s syndrome?
Oral steroids
Pituitary Cushing’s disease
Ectopic ACTH
Adrenal Adenoma
An obese 35 year old patient has the following results:
9am cortisol (Monday): 650 nM Given 0.5 mg dexamethasone every 6 hours for 48 hours 9am cortisol (Wednesday) < 50nM What is the diagnosis? What should be done next ?
Normal Obese person
Tell her she doesn’t have a problem
9am cortisol (Monday): 650 nM
Given 0.5 mg dexamethasone every 6 hours for 48 hours
9am cortisol (Wednesday) 500nM
What is the diagnosis?
Cushing’s syndrome of indeterminate cause - then use pituitary sampling to determine cause
9am cortisol (Wednesday): 500 nM Given high dose dex suppression 9am cortisol (Friday) 170nM What is the diagnosis?
Pituitary dependant Cushing’s Disease
What are the layers of the adrenals?
Glomerulosa -Aldosterone (thin)
Fasciculata - Cortisol (thick)
Reticularis - steroids
Medulla - Epinephrine/ norepinephrine
What is the website to look at path pictures?
https://webpath.med.utah.edu/ENDOHTML/ENDO003.html
What happens in IPSS?
Measure prolactin at baseline
Give pt injection of CRH in petrosal sinus
Tumour pushes out ACTH (if pituitary)
