Adrenal dysfunction

Question 1

primary adrenal insufficiency causes

Answer 1

1. Addisons autoimmune
2. Infectious TB, Fungi HIV
   infiltrative (amyloid)
   hemmorhage
   metabolic
   surgery

Question 2

adrenal insufficiency symptoms

Answer 2

Fatigue Anorexia Abdominal Pain
Weakness Myalgias /Arthralgias
Postural Dizziness
Headaches Salt Craving N/V Weight Loss

Question 3

Adrenal insufficiency signs

Answer 3

Signs All Signs (1o Only)
Hypotension Vitiligo
Tachycardia Pigmentation

Question 4

Adrenal insufficency Lab values

Answer 4

Laboratory
Hyperkalemia (1o Only) Azotemia
Hyponatremia Anemia
Hypoglycemia Eosinophilia

Question 5

diagnosing primary AI

Answer 5

Serum Cortisol
100 pg/ml

Adrenal CT Scan
Small: Autoimmune, Metabolic
Large: All Other Causes

Question 6

causes of secondary AI

Answer 6

supraphysiologic Glucocorticoids for > 3 weeks, Opioids
Tumor, Metastatic
Surgery, Radiation
Infectious, Infiltrative
Hemorrhage

Question 7

DX of secondary AI

Answer 7

Serum Cortisol

Question 8

AI Tx

Answer 8

Glucocorticoid Replacement (Primary + Secondary)
Hydrocortisone: 15-25 mg/day
Prednisone: 4-5 mg/day
Dexamethasone: 0.75 mg/day

Mineralocorticoid Replacement (Primary Only)
Fludrocortisone: .05-0.1 mg/day

Question 9

Primary aldosteronism sub types and Tx

Answer 9

APA- aldosterone producing adenoma 34%
APA: Surgical Management is an Option
- preop aldosterone antagonsists

IHA- Idiopathic Hyperaldosteronism 66%
IHA: Medical Management Only
-aldosterone antagonsits plus CCB/ACEI/ARB

Question 10

screening and confirmation tests for primary aldosteronism

Answer 10

Morning Sample:
     Plasma Aldosterone (PA)
     Plasma Renin Activity (PRA)
Positive Screen:
 PA > 15 ng/dl  AND
 PA/PRA Ratio > 20

Confirmation Tests
Sodium Suppression Testing
Oral Salt Load (High NaCl Diet x 3 Days)
IV Saline Infusion (2 L NS over 4 Hours)

Diagnostic Results:

Oral Salt Load
24 hr Urine Aldosterone (3rd day) > 12 ug
IV Saline Infusion
PA > 10 ng/dl

Imaging 
Anatomic Tests
 CT (best),  MRI
Functional Tests
 FDG-PET, NP-59 Adrenocortical Scintigraphy
Interventional Tests
 Adrenal Venous Sampling

NP-59 Adrenocortical Scintigraphy
-cholesterol analog - binds to adrenal LDL
receptors (cholesterol is base for steroid hormones)
Adenoma: Unilateral Visualization
Hyperplasia: Bilateral Visualization
Sensitivity: 50-100%

Question 11

Pheo Triad

Answer 11

Pheochromocytoma Triad: Hypertension Plus

Headaches, Sweating, Palpitations

Question 12

rule of 10%

Answer 12

10% are Malignant
10% are Familial
10% are Bilateral
10% are Extra-Adrenal

Question 13

pheo familial syndromes

Answer 13

Multiple Endocrine Neoplasia Type 2A
-Medullary thyroid carcinoma 
-Pheochromocytoma
-primary hyperparathyroidism
Multiple Endocrine Neoplasia Type 2B
--Medullary thyroid carcinoma 
-Pheochromocytoma
-primary hyperparathyroidism
-Mucosal neuroma 

Von Hippel Lindau Syndrome
Neurofibromatosis Type 1
Familial Paragangliomas (SDH Mutations)

Question 14

pheo screening tests

Answer 14

Metanephrines 90% 98%
plus Catecholamines

Plasma Metanephrines 97% 85%
Best Screening Test: Urine Metanephrines and Catecholamines

Question 15

pheo localization

Answer 15

Majority > 4 cm in Size

Abdominal
MRI or CT Scan

I-123 MIBG Scan
In-111 Pentreotide Scan

PET Scan
F18 Fluorodeoxyglucose
F18 Fluorodopamine
C11 Hydroxyephedrine
 not hard to find

Question 16

pheo prop management

Answer 16

Alpha Blockers (1st)
	Phenoxybenzamine: 20-100 mg qd
	Prazosin: 1-5 mg BID
	Terazosin: 2-10 mg QD
	Doxazosin: 1-16 mg QD
Beta Blockers (2nd – after Alpha Blockade)
Calcium Channel Blockers (alone)

Question 17

endogenous causes of cushing syndrome

Answer 17

80% ACTH secreting pituitary tumor
10% ectopic ACTH secreting tumor
10% cortisol secreting adrenal tumor

Question 18

Cushing syndrome symptoms, signs

Answer 18

Fatigue Weight Gain
Weakness *Facial Plethora
Headaches Easy Bruising

Hypertension Muscle Weakness

• Central Obesity (buffalo hump) Thin Skin
• Purple Stretch-Marks *Hirsutism

Question 19

lab findings in cushings

Answer 19

Laboratory
Hyperglycemia-counter regulatory hormone
Hyperlipidemia

Question 20

screening tests cushings

Answer 20

Screening Tests Positive Result
24 Hour Urine Cortisol Elevated
Bedtime Salivary Cortisol Elevated
1 mg DST* Cortisol > 1.8 ug/dl

Question 21

cushing differential DX

Answer 21

Condition ACTH (Plasma) DST (8 mg)
Pituitary ACTH Normal/High Suppression
Secreting Tumor

Ectopic ACTH High/Very High NoSuppression
Secreting Tumor

Adrenal Cortisol Low No Suppression
secreting tumor

Question 22

cushing localization

Answer 22

Pituitary MRI
Chest CT
Abdominal CT
Inferior Petrosal Sinus Sampling

Question 23

cushing tx

Answer 23

Surgery: Pituitary, Chest, Abdomen

ACTH Secretion Inhibitors
Cabergoline, Pasireotide

Cortisol Synthesis Inhibitors
Ketoconazole, Metyrapone, Etomidate

Adrenolytic Agents
Mitotane

Cortisol Receptor Blockers
Mefispristone