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Endo > Cortisol Disorders > Flashcards

Cortisol Disorders Flashcards

1
Q

primary function of the adrenal gland

A

Make mineracorticoids and glucocorticoids

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2
Q

How does stress trigger cortisol release?

A

Stress triggers hypothalamus to secrete CRH -> CRH triggers anterior pituitary to secrete ACTH -> ACTH triggers adrenal gland to secrete cortisol

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3
Q

What does cortisol stimulate?

what does it stimulate?

A
  • Immune system -> produce cytokines, inflammatory cascade and additional WBC
  • Liver -> gluconeogenesis to incr gluc and lipid metab
  • Kidneys -> retain salt to maintain volume
  • Vasoconstriction -> incr BP
  • Heart -> incr HR
  • Hypothalamus -> STOP releasing CRH (negative feedback loop)

at sufficient cortisol levels, negative feedback loop. Cortisol will stim hypothalamus to stop releasing CRH

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4
Q

What layer of the adrenal gland secretes glucocorticoids?

A

Zona fasculata of the adrenal cortex

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5
Q

Glucocorticoids role in the body?

A
  • steroid hormones produced from adrenal cortex
  • major role in the metabolism of glucose, protein, and fat
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6
Q

Connect the dots between cortisol and cholesterol synthesis

A

ACTH triggers cortisol secretion. ACTH also activates HMG CoA (rate limiting enzyme in cholesterol synthesis). Cortisol levels and cholesterol synthesis are highest at 8AM and lowest b/w 12AM and 4AM

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7
Q

What is the HPA Axis?

A

Hypothalamic-Pituitary-Adrenal Axis Feedback Loop
(ACTH -> Adrenal Gland -> Cortisol)

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8
Q

does cortisol cause hyper or hypo - glycemia?

A

Hyperglycemia

  • upregulates or activates or induces enzymes involved in gluconeogenesis and glycogenolysis.
  • Inhibitsinsulin and decreases the cellular uptake of glucose to increase the availability of glucose for the brain, red blood cells, and skeletal muscles.
  • Stimulates skeletal muscle breakdown to mobilize amino acids for liver to perform gluconeogenesis. (glucose from amino acids)
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9
Q

is cortisol inflammatory or anti-inflammatory?

A

anti-inflammatory

  • Promote WBC maturation and release from bone marrow
  • Decrease the cell death of neutrophils (first responder)
  • Increase cell death of eosinophils (allergy histamine)
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10
Q

neuro effects of cortisol

A

hard to sleep
depression
hyperstimulation

  • Hyperstimulation which results in difficulty falling asleep, a decrease in REM sleep latency, and often presents as depression.
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11
Q

Adrenal Excess of Cortisol is referred to as ____

A

Cushing’s Syndrome

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12
Q

2 main ways you get Cushing’s Syndrome

bigger picture

A

too many glucocrticoids (too much cortisol) via
1. Endogenous - pituitary or adrenals fault
2. Exogenous - taking steroids

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13
Q

Cushing’s Disease vs Cushing’s Syndrome

A

Endogenous pituitary tumor = Disease
collection of symptoms (any tumor NOT pituitary or exogenous) = Syndrome

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14
Q

Pt presents with H/A, Polyuria, Nocturia, Visual provlems, and galactorrhea. Dx?

A

Cushing’s Syndrome

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15
Q

what does glucocorticoid excess do to your hair?

A

Women -> hirsuitism (facial hair)
Men -> balding on head and excess hair other places

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16
Q

How does Cushing’s cause Galactorrhea?

A

Anterior pituitary tumors compress the pituitary stalk -> HIGH prolactin levels

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17
Q

pt with suspected cushing’s shows HGIH ACTH and Cortisol. What is the likely cause?

A

primary tumor in pituitary

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18
Q

Norm ACTH and HIGH cortisol.
Is this primary tumor Cushing’s Disease or Cushing’s Syndrome due to steroid use?

A

Steroid use (Cushing’s Syndrome)

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19
Q

Norm ACTH and HIGH Cortisol.
Cushing’s Disease or Syndrome?

A

Syndrome

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20
Q

Cushing’s WU

A
  • 24 hour urinary free cortisol level
  • low-dose dexamethasone suppression test
  • evening serum and salivary cortisol level
  • dexamethasone–corticotropin-releasing hormone test.
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21
Q

what time of day is best to do a cushing’s serum and salivary cortisol level

A

at night when it should be highest ONLY in those with cushing’s

22
Q

Test to differentiate Cushing’s Syndrome vs Disease

A

Dexamethasone Suppression Test

23
Q

Cushings

Dexamethasone Suppression Test

A
  • Steroids inhibit secretion of CRH and ACTH
  • Give dexamethasone and then check plasma cortisol level & dexamethasone levels
  • Cortisol levels should be low after giving dexamethasone (“suppression is present”)

Low Dose Test
Suppression is absent in Cushing Syndrome bc the issue is a tumor on the adrenal gland (downstream)

High Dose Test
- Suppression is present in Cushing Disease bc the high dose is enough to suppress pituitary tumor secreting ACTH (upstream)
- Suppression is Absent in Cushing Syndrome due to ectopic ACTH secretion or adrenal abnormalities

24
Q

Imaging orders for cushings?

A

Adrenal -> Abd CT
Pituitary -> Brain MRI W/Contrast
Ectopic -> chest/Abd CT

25
Q

Cushings Trmnt

A
26
Q

Adrenocortical insufficiency is referred to as _______ Disease

A

Addison

27
Q

80% of Addison Dz is due to ______
10% of Addison Dz is due to ____

A

80% idiopathic
10% TB (granuloma deposition)

28
Q

AIDS pts with low CD4 cell count are more susceptible for opportunistic infx such as _____, which may lead to Addison Disease

A

cytomegalovirus
Mycobacterium avium intracellulare
cryptococci

29
Q

Drugs that can cause Addison Disease

A

Ketaconazole
Methadone (depletes pituitary ACTH)
Abd radiation

30
Q

Addison Disease

A
31
Q

Effects of Cortisol

A
32
Q

Aldosterone’s Effects

A

promotes reabsorption of sodium and secretion of potassium and hydrogen to increase intravascular volume.

33
Q

What factors can trigger an Adisonian crisis?

A

Stress factors:
stress
infx
trauma
Sx
Vomiting
Diarrhea
Replacement steroids noncompliance

34
Q

SS of CHRONIC Adison Disease

A
  • Skin Hyperpigmentation
  • Vitiligo (autoimmune melanocyte destruction)
  • N/V/D, Steatorrhea
  • Weakness, fatigue, poor appetite, wt loss
  • Dizzy, Orthostatin HypoTN
  • Myalgias
  • SALT CRAVING, heightened sense of smell, taste, hearing
  • impotense, decr libido
  • Amenorrhea
  • Pt with DM may suddenly req LESS insulin and have more hypoglycemic episodes due to this incr in insulin sensitivity
35
Q

These skin changes are signs of which cortisol disease?

Skin Darkening Vitiligo
A

Addison Disease

Hyperpigmentation
Excess ACTH causes melanocytes to produce melanin
Most prominent on sun-exposed areas (extensor surfaces, knuckles, elbows, knees, scars formed after onset of disease). Scars formed before onset of disease usu are not affected

Vitiligo
autoimmune destruction of melanocytes

36
Q

Addison Disease Test

A

Rapid ACTH Stimulation Test

  1. Inject ACTH
  2. see if plasma cortisol and aldosterone levels are higher or lower than basal levels
37
Q

rapid ACTH stimulation test interpretation

Increase in plasma cortisol and aldosterone levels (above basal level) after injecting ACTH

A

(-) Test
Normal adrenal cortex function

38
Q

rapid ACTH stimulation test interpretation

aldosterone baseline is low and fails to double

A

Abnormal Mineralcorticoid Fn

39
Q

rapid ACTH stimulation test interpretation

In times of stress, there may be a normal appearing amount of cortisol at baseline, however, it will not significantly increase in response to ACTH (+7) because production is already maxed out.

A

Abnormal Glucocorticoid Fn

40
Q

Expected CMP for Addison Disease?
Na+
K+
Ca+
Gluc
BUN/Creat
GFR

High or low?

A

LOW Na+ (hyponatremia)
High K+ (Hyperkalemia)
High Ca+ (hypercalcemia)
Low Gluc (Hypoglycemia)
High BUN/Creat
Low GFR

41
Q

Imaging order for Addison Disease

A

Abdominal CT
* Due to TB or Histoplasmosis -> Calcified adrenal glands
* Autoimmune Addison Dz -> Atrophied adrenal glands

42
Q

Addison Disease Trmnt

A
  • Refer to Endo
  • Glucocorticoid replacement -> Prednisone
  • Mineralcorticoid replacement ->** Fludrocortisone / Florinef**

  • Prednisone -> 5-60 mg/day PO in single daily dose or divided q6-12hr
  • Fludrocortisone/Florinef -> On average: 0.1 mg/day PO, range: as low as 0.1 mg 3 times a week to .2mg/day
43
Q

Pt with Addison Disease reports morning headaches, weakness, dizziness, and ss of hypothyroidism. Endocrinologist has them on Prednisone and Fludrocortisone. Concern for what?

A

inadequate replacement of glucocorticoids and mineralcorticoids. They might need their meds increased

44
Q

Pt with Addison Disease reports with moon face, buffalo hump, sudden wt gain, and other cushings features. Endocrinologist has them on Prednisone and Fludrocortisone. Concern for what?

A

signs of over-replacement
They may need their meds decreased

45
Q

Aside from an Abdominal CT scan, what other imaging scan may you order for a pt with Addison Disease?

A

DEXA scan to detect early osteoporosis

46
Q

Pt with Addison Disease is about to have surgery. They are on replacement Prednisone (Glucocorticoid) and Fldrocortisone (Mineralcorticoid). What medication changes will you make?

A

Glucocorticoid must be replaced during surgery. Give Hydrocortisone 100mg IM -> continous IV infusion -> rapid taper within 24-36hrs to usual replacement dose

mineralcorticoid replacement is usu NOT needed

47
Q

What do you expect to see in a history of a pt with Addisonian/Adrenal Crisis?

A
  • Prior steroid use (>20mg daily prednisone for >5 days within past year)
  • Infx: H. flu, S. aureus, S. pneumonia, fungi
  • Physio Stress (sepsis, trauma, burns, sx)
  • Rapid withdrawal of long-term steroid therapy (>10mg prednisone daily)
48
Q

Pt with Addison Disease presents with N/V, Vascular collapse (hypovolemic shock), confusion, hyperpyrexia, and HIGH fever (105F). Concern for?

A

Addisonian/Adrenal Crisis

49
Q

Addisonian Crisis Causes

A
  • **Stress
  • Failure to incr daily replacement steroid doses in times of stress/illness**
  • failure to incr steroids
  • failure to adjust replacement in pts taking CYP450 drugs (rifampin, Dilantin)
  • Bil adrenal hemorrhage due to Meningococcus or Pseudomonas Infx, Pregnancy, Heparin/warfarin, SLE)
50
Q

The surgeon forgot to give hydrocortisone (replacement glucocorticoid) during trauma surgery. Now, you have to closely monitor for signs of ______

A

Addisonian Crisis

Signs of hypovolemic shock: N/V, vascular collapse, acute abd like ss, hyperpyrexia, high fever (105F), coma

51
Q

Pt presents with hypovolemic shock ss. Parents say pt sees an endo for “something with her cortisol.” Labs show plasma cortisol >25mcg/dL. Is this adrenal insufficiency?

A

No, their adrenals are working well if they are producing cortisol >25mcg/dL. This EXCLUDES Addison Disease

52
Q

Addisonian Crisis trmnt

A
  • IVF 0.9% NS or D5NS if glucose is needed
  • Hydrocortisone infusion

Endo (10 decks)

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