Adrenal Disorders

Question 1

why does Hyponatremia (low Na), Hyperkalemia (high K), Hypotension (low BP) occur in Primary Adrenal Insufficiency

Answer 1

because of the mineralocorticoid deficiency -> no aldosterone -> affects Na and K channels in priniciple cells of tubule

Question 2

why does hyperpigmentation occur in Primary Adrenal Insufficiency

Answer 2

Increased ACTH production -> so there is also an increase POMC (a precursor). MSH (Melanocyte stimulating hormone) is also a product POMC

Question 3

Testing for Primary Adrenal Insufficiency consists of _____

Answer 3

1) morning serum cortisol level (if less than 16 mg/dL) then …
2) 250 mcg IV cosyntropin over 2 mins -> measure cortisol at 30 and 60 min if cortisol less than 20 mg/dl then AI is the diagnosis

Question 4

whats the difference in Treatment for primary vs secondary Adrenal Insufficiency

Answer 4

In Primary replace both glucocorticoids and mineralocorticoids, whereas secondary is only glucocorticoid replacement

Question 5

what are the Causes of Hyperaldosteronism

Answer 5

1) Primary aldosteronism (Conn’s)
2) Secondary aldosteronism: Cirrhosis, heart failure
3) Liddle’s Syndrome: mutation in epithelial sodium channel
4) Deoxycorticosterone mediated: Genetic recombination of genes
5) Licorice ingestion: pseudohyperaldosteronism

Question 6

what are the signs and symptoms of primary Aldosteronism

Answer 6

Resistant hypertension 
Hypokalemia*
Mild hypernatremia
Metabolic alkalosis
Muscle weakness can occur

Question 7

Who should be screened for primary hyperaldosteronism

Answer 7

Under 30 with HTN,
Hypokalemia and HTN
Resistant hypertension (on 2 meds)

Question 8

patients who lack cortisol have _____ that is poorly responsive to _________

Answer 8

low blood pressure,

Pressors (norepinephrine, epinephrine, dopamine).

Question 9

what are some causes of SECONDARY ADRENAL INSUFFICIENCY

Answer 9

1) Following supraphysiological doses of exogenous glucocorticoids for more than 3 weeks
2) Opioids
3) Following cure of Cushing’s syndrome
4) Hypothalamic/pituitary lesions: tumor, surgery in the area, radiation, infectious, hemorrhagic, infiltrative, metastatic disease to the area

Question 10

Patients with primary gland (adrenal) failure will have what lab values related to cortisol and aldosterone
whereas

Answer 10

hyponatremia but hyperkalemia,

Question 11

Patients with secondary disease have preserved aldosterone synthesis from the adrenal gland and are therefore ______, regarding labs.

Answer 11

normokalemic

Question 12

______ is by far the most common cause of primary adrenal insufficiency in developed countries, whereas _______remains the most common cause in developing countries.

Answer 12

Autoimmune destruction of the adrenal gland (Addison’s disease) ,
tuberculosis

Question 13

Adrenal insufficiency is associated with other autoimmune disorders, such as _____

Answer 13

Hypothyroidism (25%)
Graves’ disease (11%)
Primary ovarian (13%) or testicular (2%) failure
Type I diabetes mellitus (10%)
Autoimmune hypoparathyroidism (4%)

Question 14

what are the four basic types of primary aldosteronism

Answer 14

1) Aldosterone-producing adenoma (APA) (34%)
2) Idiopathic hyperaldosteronism (IHA); a.k.a. Bilateral Adrenal Hyperplasia (66%)
3) Glucocorticoid-remediable hyperaldosteronism (GRA) (rare)
4) Aldosterone-producing carcinoma (rare

Question 15

what is the treatment for bilateral adrenal hyperplasia is causing Hyperaldosteronism

Answer 15

mineralocorticoid antagonist (spironolactone 25-100 mg daily or eplerenone

Question 16

What Can Cause Pseudohyperaldosteronism

Answer 16

Licorice

Question 17

describe the screening test for hyperaldosteronism

Answer 17

measure baseline aldosterone (PA) and plasma renin activity (PRA) levels. If the PA/PRA ratio is > 20 with a PA > 15 ng/dL, this is highly suggestive of primary aldosteronism.

Question 18

what can interfere with the screening test for hyperaldosteronism and should be avoided or discontinued before the testing

Answer 18

Spironolactone use

Question 19

If PA/PRA ratio is elevated, what should you do next?

Answer 19

salt suppression test
Need to demonstrate inappropriate aldosterone secretion after salt loading
Given 2L normal saline over 4 hours and measure aldosterone
Normal: aldosterone suppresses below 5 ng/dL
Hyperaldo: aldosterone above 10 ng/dL

Question 20

Once a biochemical diagnosis of hyperaldosteronism is certain, what should be done next?

Answer 20

CT or MRI should be performed to look for adenoma or hyperplasia

Then adrenal vein sampling (AVS) should be done for lateralization

Question 21

In adrenal vein sampling. if there is Unilateral elevation of aldosterone,the a/an _____ is suspected, while bilateral elevation of aldosterone suggests ______

Answer 21

adenoma,
idiopathic hyperaldosteronism (IHA)

Question 22

how is an adrenal adenoma treated?

Answer 22

surgical excision

Question 23

How is idiopathic hyperaldosteronism (IHA) treated

Answer 23

aldosterone antagonist (spironolactone or eplerenone) and other antihypertensive medications

Question 24

Tumors that occur in extra-adrenal chromaffin tissue anywhere along the sympathetic chain or parasympathetic chain are referred to as _____

Answer 24

paragangliomas

Question 25

what are the classic triad of symptoms seen in pheocromocytomas

Answer 25

Headache
Palpitations
Sweating

Question 26

what are some of the drugs that can interfere with testing for pheocromocytomas?

Answer 26

Acetaminophen,
SSRI's
SNRI's
Tricyclic antidepressants
marijuana and other illicit drug use

Question 27

Treatment of pheochromocytomas is achieved by surgical removal after appropriate medical peri-operative blockade to avoid a hypertensive crisis during surgery. Peri-operative blockade is started with _____

Answer 27

alpha-adrenergic receptor blocker (First line: phenoxybenzamine, Second line: prazosin, terazosin or doxazosin) followed by a beta blocker (once full alpha blockade is achieved), or a calcium channel blocker (as part of the second line treatment).

Question 28

an adrenal nodule is likely benign on CT scan if ____

Answer 28

HU < 10 on non-contrast CT

Question 29

Benign lipid rich nodules have signal drop out on _____ MRI imaging

Answer 29

out of phase

Question 30

what are the Imaging Characteristics of Benign Adrenal Masses

Answer 30

Less than 4cm
Homogeneous with smooth or regular borders
HU <10 on non-contrast CT scan
Rapid enhancement of contrast; rapid loss of contrast
>50% washout

Question 31

what are the characteristics of Adrenocortical carcinoma

Answer 31

Large: >4cm.
HU > 20,
Low washout

Question 32

All adrenal nodules should be ruled out for hormonal hypersecretion by what screening tests

Answer 32

Plasma metanephrines or 24hr urine mets/cats
Screens for pheochromocytoma
1 mg overnight dex suppression test
Screens for hypercortisolism

Question 33

If patient is hypertensive and has an adrenal incidentaloma, screen for ______

Answer 33

primary aldosteronism

aldosterone/plasma renin activity

Question 34

The most common cause of cushings syndrome is _____

Answer 34

iatrogenic: due to the chronic administration of glucocorticoids in the treatment of autoimmune or inflammatory disorders

Question 35

what are the screening tests for cushings?

Answer 35

24 hr urinary free cortisol (UFC) determination, overnight 1 mg dexamethasone suppression test (DST)

Question 36

what is an abnormal result in the dexamethasone supression test

Answer 36

8 AM plasma cortisol is > 1.8 micro grams/dL

Question 37

when can Cushing’s syndrome be excluded from the differential

Answer 37

When 24 hr Free urine cortisol and dexamethasone supression tests are normal