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Endocrine > Adrenal Insufficiency > Flashcards

Adrenal Insufficiency Flashcards

1
Q

cortisol binds ___ in plasma

A

CBG

(also albumin to lesser extent)

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2
Q

primary vs secondary adrenal insuf clinical presentation differ because

A

in primary, aldosterone is also absent

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3
Q

adrenal venous drainage

A

right adrenal vein to posterior IVC

left directly to left renal vein

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3
Q

ACTH secreting neoplasms in Cushings have a higher set point for ____

A

glucocorticoid negative feedback

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3
Q

earliest biochemical finding in cushings

A

lack of nadir or cortisol secretion late at night

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4
Q

pathophysicology ACTH independent hypercortisolism

A

solitary tumor or bilateeral adrenal nodular disease

ACTH low in patients due to corisol negative feed back, making contralteral adrenal small

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5
Q

lab abnls in adren insuf

A

hyperkalemia (primary)

hypercalcemia, hypoglycemia (rare in adults)

lymphocytosis

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5
Q

Rx cause of pituitary disease related secondary adrenal insufficiency

A

ipilimumab

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6
Q

Primary adrenal insufficiency =

Secondary adrenal insufficiency =

Teritiary adrenal insufficiency =

A

impaired production of cortisol from adrenal cortex due to dysfunctional adrenal gland

diseases of pituitary (ACTH def)

diseases of hypothalamus (CRH def)

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6
Q

2 caveats for cortisol testing outcomes

A
  1. chronically ill may have low binding proteins - low total cortisol with normal free levels

(estrogen, contraception may increase cortisol levels reflecting increase in binding proteins with no adrenal dyfunction

  1. adrenal androgen production is a sensitve marker of adrenal reserve and normal levels are very rare in adrenal insuff
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7
Q

concurrent disorders common with adrenal insuff

A

critical illness with hypotension

pituitary diseasse

TBI

Brain radiation

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8
Q

explanation of skin pigmentation changes with marke ACTH elevation

A

presence of alpha melanocyte stimulating hormone amSH within peptide hormone complex POMC from which ACTH is processed from

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8
Q

Rx causes of adrenal insuff

A

Withdrawal from corticosteroids

narcotics (supress CRH/ACTH)

Ketoconazole, etomidate, mitotane (adrenostatic/lytic)

mifepristone (glucocorticoid receptor antagonist)

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9
Q

presenting symptoms adrenal insufficiency

A

fatigue, low energy

nausea/vomiting/weight loss

hypotension > dizzyness, orthostasis

increased skin pigmentation and salt craving (primary)

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9
Q

response to acute adrenal crisis

A

Admin hydrocortisone 100mg IV every 6hrs for 24hr

once stable, taper 50mg every 6 hours and then taper to maintenance

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11
Q

porgesterone compound used to stimualte apetite and cause suppression of ACTH and cortisol

A

megestrol acetate

12
Q

congenital causes of adrenal insuf

A

congenital adrenal hyperplasia

adnrenoleukodystrophy (X-linked with accumulation of very long chain FAs in adrenals and brain)

13
Q

normal cortisol response to ACTH//Cosyntropin

A

peak resposne at 30 or 60 min >18ug/dL (500nmol/L)

14
Q

Treatment and Rx for Cushings syndrome

A

Surgery (ressection or bilateral adrenalectomy if refractory)

Radiotherapy

Pasireotide - somatostating receptor antagoinist

Metyrapone - 11-betahydroxylase inhibitor (p450 c11)

Mifepristone - glucocorticoid receptor antagonist

16
Q

cortisol exerts ___ feedback on CRH/ACTH

A

negative

17
Q

presenting symptoms that raise suspicion for Cushings

A

Weight gain (truncal)

SUpraclavicular and dorsocervical fat

facial rounding and plethora

proximal muscle weakness

Hirsutism, angrogen excess in females

Wide violaceous stria

Easy bruising, cutaneous atrophy

Cognitive difficulty, depression, psychosis

19
Q

Cortisol mechanism of action

A

Binds gluccocorticoid receptor >

> dissociation of heat shock proteins + dimerization >

> dimers translocate to nucleus > enhance glucocorticoid related genes.

21
Q

in 17-hydroxlyase deficiency, ____ makes up for deficiency of corisol

A

corticosterone

22
Q

causes of primary adrenal insuf

A

Autoimmune

Adrenal hemorrhage (associated with coagulopathis, bilateral)

Infectious (TB, histoplasmosis, coccidiomycosis, HIV)

Genetic

Infiltrative (amyloidosis, hemochromatosis)

Drugs (ketoconazole, metyrapone, mititoane, etomidate)

(Autos Are Infectious, Impressive Diversions)

23
Q

injectable hydrocortisone for emergent use

A

Solu-Cortef

24
Q

if in suspected ACTH dependent Cushings, if MRI of pituitary is normal or equivocal >

outcomes?

A

bilateral pitrosal sinus sampling with ACTH admin

no gradient = occult ectopic ACTH

gradient = cushings disease

25
Q

Drugs associated with primary adrenal insuf

A

Ketoconazole

metyrapone

mitotane

etomidate

26
Q

diagnostic tests for cushings

A

Late night salivary cortisol - lack of nadir

Overnight dexmethasone supression test - normal suppression = cortisol

24 hour urine free cortisol (poor senstivity)

28
Q

ACTH is processed from ___ inside the pituitary gland corticotropj

A

POMC

30
Q

initiating process in cortisol synthesis

A

cholesterol import into mitochondrion via StAR protein

31
Q

first step in DDx for Cushings

outcomes?

A

measure plasma ACTH

Low = independent Cushings > Adrenal CT

Normal or elevated = ACTH dependent > MRI of pituitary

32
Q

glucocoritcoid receptor antagonist used for endogenous hypercortisolism

A

mifepristone

33
Q

in kidney, cortisoal metabolized to cortisone via

and converted back to cortisol via ____ inside the _____

A

11B-HSD2

back via 11B-HSD1 in liver and visceral fat

34
Q

aldosterone pathway in zona glomerulosa is stimulated by

A

ang II

Potassium

ACTH

35
Q

diagnoses that raise suspicion for Cushings

A

Diabetes/HTN/metabolic syndrome

Osteoporosis

Adrenal nodules

36
Q

intitial evalulation of suspected adrenal insuff

follow-up

A

morning cortisol

cosyntropin stimulatory test of adrenal reserve

37
Q

steroid production in zona fasciculate controlled by

A

ACTH (via hpyothalamus)

CRH

AVP

(also negative feedback(

38
Q

lab findings Primary vs secondary adrenal insuf

A

Pimary High ACTH

HIGH PRA

low Aldosterone

**Secondary: **low-normal ACTH

normal PRA

normal aldosterone

Endocrine (45 decks)

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