Adrenal disorders

Question 1

name a condition that affects the production of each of the adrenal hormones.

Answer 1

aldosterone - Conn's 
cortisol - cushings (hyperfunction)
cortisol - addisons (hypofunction)
sex hormones - congenital adrenal hyperplasia 
epinephrine - phaeochromocytoma

Question 2

what is the cause of Conn’s syndrome?

Answer 2

over production of aldosterone caused by a tumour of the pituitary gland

Question 3

what is the presentation of a paeochromocytoma?

Answer 3

episodic / paroxysmal attacks;

• palpitations
• sweating
• pallor
• headache
• tremor
• anxiety / fear

Question 4

what is the most common cause of addison’s disease?

Answer 4

autoimmune destruction of the adrenal glands

Question 5

what is the presentation of Addison’s disease?

Answer 5

fatigue
weakness
anorexia / weight loss
salt craving 
unexplained vomiting or diarrhoea 
postural symptoms
hypotension 
skin pigmentation / vitiligo

Question 6

what is commonly associated with Addisons disease?

Answer 6

other autoimmune conditions because if you have one your are likely to have another such as;

• type 1 diabetes
• thyroid disease (hashimotos)
• premature ovarian failure

Question 7

when carrying out a random cortisol if there is suspicion of addisons disease, what values would suggest addisons or not?

Answer 7

> 700 nmol/L = not addisons

< 700 nmol/L (adrenal status still uncertain but may be addisons)

Question 8

what is the name of the confirmatory test for diagnosing addisons?

Answer 8

Synacthen test

Question 9

what is the treatment for addisons?

Answer 9

hydrocortisone therapy 20-30mg
- given in divided dose i.e. 20mg in the morning and 10mg at dinner time

prednisolone 7.5mg
dexamethasone 0.75mg
mineralocorticoid therapy - flurocortisone 50-300mg (resolve the hypotension & hyponatraemia)

Question 10

why can addison’s cause hypotension and salt cravings?

Answer 10

with cortisol insufficiency from the hypofunctioning adrenal gland , it can also cause hypo secretion of mineralocorticoids - aldosterone

Question 11

what are the causes of cushings syndrome?

Answer 11

pituitary tumour
actopic ACTH secretion from lung carcinoma
adrenal tumour
corticosteroid therapy

Question 12

what is the presentation of cushings syndrome?

Answer 12

central obesity
muscle atrophy 
proximal weakness
pink striae 
moon face 
hypertension
hyperglycaemia - diabetes mellitus
poor wound healing 
osteoporosis 
hirsutism 
amenorrhoea / galactorrhoea 
acne 
personality changes / depression

Question 13

how would you screen for curhsings syndrome?

Answer 13

24 hour urine free cortisol

1mg overnight dexamethasone test

Question 14

what results in the tests of low dose and high dose dexamthasone would be suggestive of cushings disease (tumour in the pituitary)?

Answer 14

with a low dose dexamthasone the cortisol levels are still high - doesnt respond
but it responds to high levels as the cortisol levels will derease

Question 15

what is the plasma renin activity (PRA) and plasma aldosterone concentration (PAC) like in someone with conn’s syndrome?

Answer 15

plasma renin decreased

plasma aldosterone raised

Question 16

if there is increased plasma renin activity and increased plasma aldosterone concentration, what would you investigate next to come to a diagnosis?

Answer 16

increased PRA & PAC = secondary hyperaldosteronism

investigate for causes such as renovascular hypertension, coarctation of aorta, diuretic use, malignant hypertension etc
(causes of secondary hypertension that isnt caused by an endocrine condition)

Question 17

what could be the cause of a decreased plasma renin activity and a decreased plasma aldosterone concentraion?

Answer 17

congenital adrenal hyperplasia

Question 18

what tests would you carry out to establish the source of the over production of aldosterone ? (after PRA and PAC has been carried out)

Answer 18

CT scan of adrenal glands
upright posture test
adrenal venous sampling
24 hour urine aldosterone and sodium

Question 19

why is a phaeochromocytoma termed as the 10% tumour?

Answer 19

10% malignancy
10% extra adrenal
10% multiple
10% hyperpglycaemia 
but 30% has an inherited origin

Question 20

what are the first 2 tests you carry out if your suspect adrenal insufficiency?

Answer 20

plasma cortisol ( < 700nmol/L)
synACTHen test ( < 500 mmol/L)

Question 21

how do you differentiate whether the low cortisol is due to primary adrenal insufficiency or secondary?

Answer 21

plasma ACTH levels
low ACTH = secondary
high ACTH = primary

Question 22

what tests would you carry out to investigate the cause of primary adrenal insufficiency?

Answer 22

MRI adrenal glands - tumour, infarction, haemorrhage, infection
serum antibodies- Addison’s, anti 21 hydroxylase, other autoimmune conditions
screen for rarer causes such as HIV, TB, secondary malignancy

Question 23

how long is a patient on steroid therapy for it to suppress their pituitary adrenal axis?

Answer 23

> 7.5mg prednisolone daily for 3 weeks

Question 24

what adjustments do people on steroid therapy (due to adrenal insufficiency) have to make if they have vomiting/diarrhoea?

Answer 24

IM injection of hydrocortisone

not allowed to do it themselves

Question 25

what adjustments do patients on steroid therapy (due to adrenal insufficiency) have to make if they get the flu / minor illness?

Answer 25

double their dose of steroids

Question 26

what can be the cause of adrenal insufficnecy in women if its not addisons?

Answer 26

adrenal infiltration, infarction, haemorrhage or infection

Question 27

what can be the cause of adrenal insufficiency in males if its not addisons?

Answer 27

adrenal infiltration, infarction, haemorrhage, or infection

adrenoleucodystrophy

Question 28

what does the presence of very long chain fatty acids (VLCFA) in males with adrenal insuficiency indicate?

Answer 28

adrenoleukodystrophy

Question 29

what are the rare causes of addison’s disease?

Answer 29

malignancy i.e. breast, melanoma, lung
infiltration
infection i.e. TB, HIV
infarction
iatrogenic
21 hydroxyls insufficiency