Adrenal Disease

Question 1

What is Addison’s disease?

Answer 1

Primary adrenal insufficiency. Most common cause is autoimmune destruction of adrenal glands. Other causes include:
- Surgical removal, trauma, metastases (bronchial carcinoma) infections (TB/HIV), haemorrhage, infarction, sarcoidosis or amyloidosis

Question 2

What are secondary causes of adrenal insufficiency?

Answer 2

Congenital,
Base of skull fracture
Surgery/radiotherapy
Neoplasm
Infiltration of brain
Corticotropin-releasing hormone (CRH) def

Question 3

What are features of adrenal insufficiency

Answer 3

Lethargy, weakness, anorexia, nausea, vomiting, weight loss,
Hypotension
GI Symptoms
Syncope
Pigmentation (due to increased in ACTH but not in secondary)
Low sodium, low glucose, high potassium and metabolic acidosis
Age of onset is 30-50 but can occur at any age.

Question 4

What are the investigations for adrenal insufficiency?

Answer 4

• Bloods: High renin and low aldosterone,
• 9am cortisol (if <500 then do short synacthin test)
• Adrenal auto-antibodies (anti-21-hydroxylase)
• Definitive test is short synacthin test

Question 5

What is the main diagnostic test for adrenal insufficiency?

Answer 5

Short synacthen test (Measure plasma cortisol before and 30 mins after giving Synacthin which should cause a rise in cortisol and aldosterone in healthy individuals)

Question 6

What investigations may identify a cause of adrenal insufficiency?

Answer 6

• Adrenal autoantibodies
• Chest X ray
• CT of adrenal glands
• MRI brain

Question 7

What is the management of adrenal insufficiency/addison’s?

Answer 7

• Hydrocortisone and fludrocortisone
• Sick day rules: Increase glucocorticoids on sick days

Question 8

What are the potential causes of an Addisonian crisis and the treatment?

Answer 8

Causes - Sepsis/surgery, adrenal haemorrhage or steroid withdrawal.
Treatment - Aggressive fluid resus and IV steroids (hydrocortisone 100mg then 6 hourly until patient is stable. No fludrocortisone is required because the high dose of cortisol exerts weak mineralocorticoid effect)
Glucose/dextrose if hypoglycemic

Question 9

What are some causes of Cushing’s Syndrome

Answer 9

Commonly occurs due to pituitary ACTH secreting tumour (Cushing’s disease)
Non-pituitary causes of Cushing’s syndrome:
Ectopic ACTH secretion
Adrenal adenoma
Adrenal carcinoma
Exogenous steroids

Question 10

What are clinical features of Cushing’s syndrome?

Answer 10

Facial: Moon-like face, acne,
Thinning hair
Thinning of skin,
Purple striae
Easy bruising
Proximal myopathy
Central obesity
Buffalo hump
Depression and insomnia
Menstrual disturbance
Hypertension
Hyperglycaemia/diabetes
Cardiac hypertrophy
Osteoporosis

Question 11

What are the investigations for Cushing’s syndrome?

Answer 11

To confirm- 24h urinary cortisol, lowdose Overnight dexamethasone suppression test, bedtime salivary cortisol.
To localise: High dose dexamethasone - Adrenal pathology if only ACTH is suppressed and not cortisol.
Pituitary pathology if both ACTH and cortisol is suppressed.
Ectopic ACTH if neither are suppressed
Other tests include: Petrosal sinus sampling

Question 12

What is the management for Cushing’s syndrome?

Answer 12

Surgery (Transphenoidal resection)
Radiotherapy
Pharmacology - Steroid blocker eg Metyrapone

Question 13

What are the sick day rules for steroids in adrenal insufficiency?

Answer 13

Glucocorticoid dose should be doubled with fludrocortisone staying the same

Question 14

What is the presentation of an addisonian crisis?

Answer 14

Severe fatigue, hypotension, abdominal pain, nausea and vomiting, confusion or coma.

Question 15

What is the management of an Addisonian crisis?

Answer 15

1. Give hydrocortisone 100mg IM/IV.
2. 1 Litre of normal saline infused over 30-60mins. Dextrose if hypoglycaemic.
3. Continue hydrocortisone 6 hourly