Adrenal dysfunction Flashcards
primary adrenal insufficiency causes
- Addisons autoimmune
- Infectious TB, Fungi HIV
infiltrative (amyloid)
hemmorhage
metabolic
surgery
adrenal insufficiency symptoms
Fatigue Anorexia Abdominal Pain
Weakness Myalgias /Arthralgias
Postural Dizziness
Headaches Salt Craving N/V Weight Loss
Adrenal insufficiency signs
Signs All Signs (1o Only)
Hypotension Vitiligo
Tachycardia Pigmentation
Adrenal insufficency Lab values
Laboratory
Hyperkalemia (1o Only) Azotemia
Hyponatremia Anemia
Hypoglycemia Eosinophilia
diagnosing primary AI
Serum Cortisol
100 pg/ml
Adrenal CT Scan
Small: Autoimmune, Metabolic
Large: All Other Causes
causes of secondary AI
supraphysiologic Glucocorticoids for > 3 weeks, Opioids Tumor, Metastatic Surgery, Radiation Infectious, Infiltrative Hemorrhage
DX of secondary AI
Serum Cortisol
AI Tx
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
Primary aldosteronism sub types and Tx
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
screening and confirmation tests for primary aldosteronism
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%
Pheo Triad
Pheochromocytoma Triad: Hypertension Plus
Headaches, Sweating, Palpitations
rule of 10%
10% are Malignant
10% are Familial
10% are Bilateral
10% are Extra-Adrenal
pheo familial syndromes
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)
pheo screening tests
Metanephrines 90% 98%
plus Catecholamines
Plasma Metanephrines 97% 85%
Best Screening Test: Urine Metanephrines and Catecholamines
pheo localization
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
pheo prop management
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)
endogenous causes of cushing syndrome
80% ACTH secreting pituitary tumor
10% ectopic ACTH secreting tumor
10% cortisol secreting adrenal tumor
Cushing syndrome symptoms, signs
Fatigue Weight Gain
Weakness *Facial Plethora
Headaches Easy Bruising
Hypertension Muscle Weakness
- Central Obesity (buffalo hump) Thin Skin
- Purple Stretch-Marks *Hirsutism
lab findings in cushings
Laboratory
Hyperglycemia-counter regulatory hormone
Hyperlipidemia
screening tests cushings
Screening Tests Positive Result
24 Hour Urine Cortisol Elevated
Bedtime Salivary Cortisol Elevated
1 mg DST* Cortisol > 1.8 ug/dl
cushing differential DX
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
cushing localization
Pituitary MRI
Chest CT
Abdominal CT
Inferior Petrosal Sinus Sampling
cushing tx
Surgery: Pituitary, Chest, Abdomen
ACTH Secretion Inhibitors
Cabergoline, Pasireotide
Cortisol Synthesis Inhibitors
Ketoconazole, Metyrapone, Etomidate
Adrenolytic Agents
Mitotane
Cortisol Receptor Blockers
Mefispristone
