Adrenal Gland Disease

Question 1

Presentation of Addison’s

Answer 1

ADRENAL INSUFFICIENCY (cortisol and aldosterone)

-Dizziness
-Fatigue
-Weight loss
-Hypotension on standing
-Hyperpigmentation (especially palmar creases) and vitiligo
-Lethargy, anorexia, weakness
-Nausea and vomiting
-Salt-craving
-Loss of pubic hair in women
-Hypoglycaemia, hyponatraemia, hyperkalaemia.
-Crisis= hypotension, hypovolaemic shock, delirium, reduced consciousness, acute abdominal pain.

Question 2

Investigation of Addison’s

Answer 2

-Short Synacthen test (failure of cortisol to rise)
-Low cortisol, High ACTH, low aldosterone and high renin in primary
-CT abdomen and pelvis (if structural cause of adrenal insufficiency suspected)
-U&E, blood glucose, hypercalcaemia, anaemia, increased liver transaminases, raised TSH.

Question 3

Management of Addison’s

Answer 3

-Glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement, DHEA

Question 4

Presentation of Cushing’s syndrome

Answer 4

TOO MUCH GLUCOCORTICOID- CORTISOL

-Facial plethora
-Supraclavicular fullness
-Violaceous striae
-Menstrual irregularities
-Hypertension
-Glucose intolerance
-Premature osteoporosis
-Weight gain and central obesity
-Acne
-Psychiatric symptoms
-Decreased libido
-Easy bruising

Question 5

Diagnosis of Cushing’s syndrome

Answer 5

-Urine pregnancy test
-Serum glucose, hypokalaemia metabolic alkalosis
-Late-night salivary cortisol
-Overnight dexamethasone suppression test: ACTH suppressed, Cortisol non suppressed (syndrome) or suppressed (disease)
-24-hr urinary free cortisol
-Adrenal CT
-Pituitary MRI

Question 6

Management of Cushing’s

Answer 6

-Transsphenoidal pituitary adenomectomy
-Somatostatin analogue (pasireotide)
-Dopamine agonist (cabergoline)
-Steroidogenesis inhibitor (osilodrostat, ketoconazole, metyrapone, mitotane, etomidate)
-Glucocorticoid receptor antagonist (mifepristone).
-Post-surgery: hydrocortisone, testosterone, oestradiol, levothyroxine.

Question 7

Presentation of Conn syndrome

Answer 7

PRIMARY HYPERALDOSTERONISM

-Hypertension
-Hypokalaemia (muscle weakness)
-Metabolic alkalosis
-Plasma sodium more than 140
-Tetany

Question 8

Investigation of Conn syndrome

Answer 8

-Screened when hypertension with hypokalaemia or treatment-resistant
-Plasma aldosterone/renin ratio (high aldosterone, low renin)
-Plasma potassium
-HRCT/MRI abdomen and adrenal venous sampling to differentiate bilateral idiopathic adrenal hyperplasia vs adrenal adenoma

Question 9

Management of Conn syndrome

Answer 9

-Adrenal adenoma= laparoscopic adrenalectomy, bilateral adrenocortical hyperplasia= aldosterone antagonist (spironolactone), CCB mask features