Diseases of Adrenal Gland

Question 1

Clinical manifestations Adrenal insufficiency

Answer 1

• N/V
• Fatigue/weakness
• FTT
• Morning headache
• fasting hypoglycemia
• INC insulin sensitivity
• DEC gastric acidity
• DEC free water clearance

Question 2

Primary AI specific

• S/S
• A/S

Answer 2

• Dark skin/mucosa, Hyperkalemia, Hyponatremia

- A/S Primary Hypothyroidism, DM1, Vitiligo,

Question 3

2nd AI specific

• S/S
• A/S

Answer 3

• S/S: Pale skin, normal K + Na

- A/S: Central hypogonadism, GH def, DI, headache

Question 4

Type 1 autoimmune polyglandular disease S/S + A/S

Answer 4

• Adrenal Failure
• Vitiligo
• Hypothyroidism
• Gonadal failure
• DM1
• Alopecia
• Penicious Anemia
• Chronic Candidia infx

Question 5

Cortisol Levels

Answer 5

10-20 ug/dL = Normal
3.1 - 10 ug/dL = adrenal dynamic testing rq’d
<3 ug/dL = Adrenal insufficiency

Question 6

When should patients with suspected AI be tested? Why?

Answer 6

In ICU + retested as outpatients

Prevent unnecessary long-term steroid use; hypoproteinemia can cause low levels

Question 7

Dynamic tests available to assess adrenal function and ACTH reserve

Answer 7

• ACTH Test
• Insulin-induced Hypoglytcemia
• Metyrapone test

Question 8

Adrenal Imaging findings

Answer 8

• Small heart
• Adrenal calcification (TB or fungal)
• small/enlarged adrenal glands

Question 9

Acute adrenal crisis

• S/S
• Tx

Answer 9

• S/S: Circulatory collapse, dehydration, N/V, Hypoglycemia, Hyperkalemia
• Tx: Plasma ACTH. Cortisol, renin, + Aldosterone; 2-3 L Na Saline or D5 NSal; dexamethasone IV bolus and q12 hours thereafter OR IV hydrocortisone, 100 mg immediately and q 6h thereafter

Question 10

Treatment of chronic adrenal insufficiency

Answer 10

• # 1 Hydrocortisone 10-12 mg/m^2 per day; ~15 mg am, 5 mg pm
• Oral Fludrocortisone (0.05-0.2); adjust dose to S/S
• Sexual Dysfx -> DHEA 50 mg daily
• Advise liberal Na intake

Question 11

When should glucocorticoids replacement be increased?

Answer 11

Times of Stress like:

• Fevers
• Dental procedures
• invasive diagnostics

Question 12

A patient was given an increased does of GCs for a dental procedure. He developed N/V, and was switched to parental. What is the major risk?

Answer 12

Vascular instability

Question 13

Corticosteroid dose major stress (SEPSIS, shock, etc)

Answer 13

50 mg IV Hydrocortisone q8

Question 14

Cushing Syndrome Etiologies

Answer 14

• Iatragenic
• Cushing’s Disease
• Adrenal Neoplasms/Hyperplasia
• Ectopic ACTH (Lung, pancreas, kidney, thyroid, thymus)
• Psychiatric (Depression, EtOH, Anorexia, Panic Disorder)
• Familial (Carney’s)

Question 15

Common presentation of ectopic ACTH

Answer 15

No active ACTH; No S/S besides Hyperpigmentation + weakness

Question 16

Pseudo-Cushing’s Syndromes

Answer 16

Pregnancy
Depression and other psychiatric conditions
Alcohol dependence
Glucocorticoid resistance
Morbid obesity
Poorly controlled diabetes mellitus

Question 17

Bilateral micronodular or macronodular adrenal hyperplasia Tx

Answer 17

bilateral total adrenalectomy

Question 18

Intractable Cushing’s or failed surgery Tx

Answer 18

Oral mefiprestone
SC pasireotide
Ketoconazole
Etomidate

Question 19

Exogenous mineralocorticoids

Answer 19

Liquorice, carbenoxalone, fludrocortisone

Question 20

Aldosterone-secreting adenoma Tx

Answer 20

• Treat BP + Hypokalemia w/ Spironolactone or Amiloride

- Unilateral adrenalectomy after

Question 21

Bilateral Adrenal hyperplasia: Tx

Answer 21

• Control Hypokalemia w. Spironolactone or Amiloride
• Control HTN w/ antihypertensive agent
• evaluate for glucocorticoid-responsive hyperaldosteronism (trial of dexamethasone)

Question 22

What can induce PCC S/S’s?

Answer 22

Emotions, excercise, abdominal pressure, + tyrosine-containing foods

Question 23

Diagnostic testing PCC

Answer 23

1. Plasma free metanephrine or normetanephrine OE urine catecholamines
2. Check during spell
3. If normal, Perform clonidine suppression test -> No Suppression = PCC
4. CT/MRI can confirm

Question 24

PCC Tx

Answer 24

• Sx for localizes tumor

- Phenoxybenzamine (a-block) 2 weeks prior, then B-blockers before surgery