ENDO Flashcards
What is Addison’s disease?
primary adrenal insufficiency
What happens in Addison’s disease?
destruction of adrenal cortex leads to cortisol and aldosterone decrease
What are the causes for Addison’s disease?
80% autoimmunity and long term steroid therapy (happens when withdrawal) in hypo
What are the risk factors for Addison’s disease?
- Female sex
- Presence of adrenocortical autoantibodies
- Adrenal Haemorrhage
- Use of anticoagulants 5. TB
What are the symptoms of Addison’s disease?
- Fatigue (described as weakness or tiredness)
- Anorexia
- Weight loss
- Nausea
- Vomiting
(hard to diagnose as vague)
What are the signs of Addison’s disease?
- Hyperpigementation (sun exposed areas- 95% of people) – due to high ACTH
- Hypotension
What are some differential diagnosis of Addison’s disease?
- Adrenal suppression due to corticosteroid therapy
- Secondary or tertiary adrenal insufficiency (pituitary or hypothalamic lesions)
- Haemochromatosis
- Hyperthyroidism
- Occult malignancy
- Anorexia nervosa
What are the complications of Addison’s disease?
- Secondary Cushing’s syndrome
- Osteopenia/osteoporosis
- Treatment related hypertension
What are the investigations and consequential findings in Addison’s disease?
- Serum Electrolytes low sodium, high potassium (rarely elevated calcium)
- Blood Urea (may be elevated)
- FBC: anaemia present in 40% of patients + eosinophilia
- Morning serum cortisol: between 9am and 9am <83
- ACTH stimulation test
- Low glucose due to low cortisol
How do you treat an Addison’s crisis?
- Glucocorticoid and supportive therapy
- hydrocortisone sodium succinate: 50-100 mg intravenously every 6-8 hours for 1-3 days
How do you treat ongoing Addison’s disease?
Glucocorticoid plus mineralocorticoid
What are the options for glucocorticoid?
- cortisone: 10 to 37.5 mg/day orally given in 2 divided doses with two-thirds of the total dose given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.)
- hydrocortisone: 15-30 mg/day orally given in 2 divided doses with two-thirds of the total dose given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.)
- prednisolone: 2.5 to 5mg orally once daily
What mineralocorticoid is given?
Fludrocortisone: 0.1-0.2mg orally once daily
What is the prognosis for Addison’s disease?
- Should have medical alert or bracelet and syringes of hydrocortisone (100mg) incase of emergency or trauma
- Yearly Us+Es and BP
- Look for other autoimmune (pernicious aneamia)
What is Cushing’s syndrome?
clinical manifestation of pathological hypercortisolism from any cause
What are the risk factors for cushing’s syndrome?
- Exogenous corticosteroid use
- Pituitary or adrenal adenoma (endo)
- Adrenal carcinoma (endo)
What are the symptoms of cushing’s syndrome?
- Facial plethora
- Supraclavicular fullness
- Violaceous stria
- Absence of pregnancy
- Menstrual irregularities
- Absence of malnutrition
- Absence of alcoholism
- Absence of physiological stress
- Linear growth deceleration in children
- female sex
- hypertension (pseudohyperaldosteronim)
- glucose intolerance or diabetes mellitus
- premature osteoporosis or unexplained fractures
- weight gain and central obesity
- acne
- psychiatric symptoms
- decreased libido
- easy bruisability
- weakness
- facial rounding
- dorsocervical fat pads
What are the differential diagnosis for cushing’s syndrome?
- Obesity
2. Metabolic syndrome
What are the complications of cushing’s syndrome?
- Adrenal insufficiency secondary to adrenal suppression
- cardiovascular disease
- hypertension
- diabetes mellitus
- osteoporosis
- nephrolithiasis
- Nelson syndrome after bilateral adrenalectomy
- treatment-related central
- treatment-related growth hormone deficiency variable
- treatment-related adrenal insufficiency
- surgery- or radiation-related
- surgery-related hyponatraemia
- treatment-related hypogonadism
- treatment-related diabetes insipidus
If suspected Cushing’s syndrome what are the investigations and first line test and findings positive for Cushing’s?
- Midnight salivary cortisol elevated
- 1 mg overnight dexamethasone suppression test: morning cortisol >50 nanomol/L (>1.8) micrograms/dL)
- 24-hour urinary free cortisol >50 micrograms/24 hour
How would you treat Cushing’s syndrome from ACTH secreting pituitary tumour (Cushings disease)?
Transsphenoidal pituitary adenomectomy
How would you treat cushings’s syndrome from ectopic ACTH or corticotrophin-releasing hormone (CRH) syndrome
surgical resection or ablation of tumour and metastases
How do you treat cushing’s syndrome from ACTH-independent due to unilateral adrenal carcinoma or adenoma?
unilateral adrenalectomy or tumour resection
How do you treat cushing’s syndrome from ACTH- independent due to bilateral adrenal disease (hyperplasia or adenoma)
Bilateral adrenalectomy and permanent post-surgical corticosteroid replacement therapy
What is the prognosis of cushing’s?
Untreated cushing’s has high vascular mortality
What would you do if the first line test for cushing’s syndrome come back positive?
- ACTH Plasma Levels to figure out cause:
1. If high: do high dose dex test and if there is no suppression CT for ectopic site and if there is low ACTH MRI pituitary gland OR CRH stimulation test (if no rise, ectopic), (if rise, cushings disease)
2. If low: non-acth related
What other investigations could you do for cushing’s?
- urine pregnancy test: negative
- serum glucose: elevated
- 48-hour 2 mg (low-dose) dexamethasone suppression test
