Adrenal Diseases Flashcards
What are Sx of Cushing’s Syndrome?
- Weight gain
- Moon facies, central obesity
- Striae
- LIDDLE’s SIGN: paper thin skin on dorsum of hand
What is the most common cause of Cushing’s syndrome?
iatrogenic (hx of glucocorticoid use)
What is the most common cause of nondrug related Cushing’s? test?
ACTH dependent - pituitary tumor (most common)
respond to steroid suppression but at higher set point
What are a majority of ectopic ACTH tumors due to? what are signs?
malignancies (small cell lung CA)
- frequent weight loss + hypokalemia
- dong respond to high dose steroids
What are top two causes of ACTH-Independent Cushings?
- Benign Adrenal Adenoma (15%)
2. Adrenocortical CA (6%)
What are the 3 main Dx evaluations for Cushings?
- 24-hour urine - free cortisol (>3 time UNL)
- 1 mg Overnight Dexamethasone suppression
- -<5 = rules out Cushings
- ->10 = Cushings - Midnight salivary cortisol
What are 3 causes of false positives in Dx tests for Cushings?
- Depression
- Alcoholism
- Chronic anxiety
What should you do after the intial 3 Dx tests for Cushings?
Low Dose Dexamethasone
- Cortisol >5 = Cushings
- <50% suppression of UFC = Cushings
What should you do after confirming Cushing’s syndrome?
Measure ACTH from BEFORE dex
<5 = ACTH independent
>20 = ACTH dependent
What should you do after determining ACTH dependence of cushings?
CT or MRI of adrenals
ACTH dependent: image pituitary
–if no tumor >6mm, sample Inferior petrosal sinus
What are 3 tests to distinguish pituitary Cushing’s from Ectopic ACTH?
- High dose Dexamethasone Suppression
- Metyrapone Test
- CRH stimulation test
How do you interpret High dose Dexamethasone suppression for ectopic/pituitary ACTH dependent Cushings?
ectopic ACTH = fail to suppress
How do you interpret Metyrapone for ectopic/pituitary ACTH dependent Cushings?
Metyrapone inhibits 11B-hydroxylase
Normal: increase ACTH (b/c decrease cortisone production)
ectopic = fail to respond
How do you interpret CRH stimulation for ectopic/pituitary ACTH dependent Cushings?
ectopic ACTH: no increase in ACTH production
What are S/Sx of Adrenal Insufficiency?
Fatigue/weakness (95%) Anorexia Weightloss Impaired mentation Hyponatremia
What are Sx for Addison’s?
Primary Adrenal Insufficiency:
Loss of pubic/axillary hair Hyperpigmentation Salt craving Orthostatic hypotension Hyperkalemia Hypoglycemic
What are Sx for Secondary/Tertiary Adrenal Insufficiency?
Fatigue, weightloss, hypoglycemia
*MINERALOCORTICOID fxn still intact
=BP normal, K normal
What is the most common cause of Adrenal insufficiency over all?
Steroid withdrawal (rapid taper of prednisone)
What is most common cause of Primary Adrenal Insufficiency? What syndrome is associated?
Autoimmune Adrenal Insufficiency
a/w Polyendocrine Autoimmune Syndrome
What are some infectious causes of Primary Adrenal Insufficiency?
Waterhouse-friedrickson syndrome = Neisseria = adrenal hemorrhage
TB, fungal, HIV, adrenal leukodystrophy
What is the gold standard for evaluating Adrenal insufficiency?
Insulin tolerance test
How do you evaluate a Cosyntropin (ACTH) stimulation test in Adrenal Insufficiency?
Normal response = rise in cortisol to 20 uq/dl at 30 and 60 min
Addisons - never reach 20
Secondary - respond by 60 min (not 30 min)
-good for evaluating PRIMARY insufficiency
What is the Tx for Adrenal insufficiency:
- Primary
- Secondary
- Glucocorticoid, Mineralocorticoid (FLORINEF!!!!!) replacement
- Glucocorticoid
What 3 places can Adrenal CA metastasize?
Renal V
IVC
lung
