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RACP Written 2018 > Endocrine - Adrenal Disease > Flashcards

Endocrine - Adrenal Disease Flashcards

1
Q

What is secreted from the Zona Glomerulosa?

What stimulates their secretion?

A

Mineralocorticoids

  • aldosterone
  • precursors

Stimulated by:

  • angiotensin II
  • K+
  • ACTH
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2
Q

What is secreted from the Zona Fasciculata?

What stimulates secretion?

A

Glucocorticoids

  • cortisol
  • corticosterone
Stimulated by:
ACTH
IL-1
IL-6
TNF
Neuropeptidases
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3
Q

What is secreted from the Zona Reticularis?

What stimulates secretion?

A

Adrenal Androgens

  • DHEA/S
  • Andostenedione

Stimulated by:
ACTH

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4
Q

What is secreted from the Adrenal Medulla?

A

Catecholamines

  • adrenaline
  • noradrenaline
  • dopamine
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5
Q

What is the melanocortin-2 receptor? How does it work?

A

The ACTH-Receptor MC2R (melanocortin-2 receptor) acts via MC2R-Accessory protein MRAP to form a complex that is transported to the adrenal cortical membrane and binds to ACTH to stimulate cAMP

This results in upregulation of protein kinase A:

1) increased importation of choelsterol esters
2) increased activity of hormone sensitive lipase which cleaves cholesterol esters
3) increased availability and phosphorylation of transcription fractor CREB which ENHANCES SYNTEHSIS OF CYP11A1

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6
Q

Effect of glucocorticoids on liver?

A

Hyperglycaemia

  • stimulates gluconeogenesis
  • stimulates glucose production from protein
  • stimulates insulin production
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7
Q

Effect of glucocorticoids on muscle?

A

Catabolism

  • mobilisation of amino acids
  • inhibition of glucose uptake in muscles
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8
Q

Effect of glucocorticoids on adipose?

A

Fat deposition

  • inhibition of glucose uptake promoting lipolysis
  • counteracted y increased insulin stimulating lipogenesis
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9
Q

Effect of glucocorticoids on immune system?

A

Increased neutrophils

Decreased T and B cells, basophils and eosinophils

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10
Q

Effect of glucocorticoids on bone?

A

Bone catabolism

  • decreased bone formation (direct inhibition of osteoblast)
  • stimulation of bone resorption
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11
Q

Effect of glucocorticoids on vascular system?

A

Increased sensitivity to vasoconstrictors
Mineralocorticoid like effect
Increased free water excretion

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12
Q

Acute and chronic causes of adrenal failure?

A

Acute: haemorrhage or infarction

  • heparin / warfarin
  • sepsis
  • coagulopathy

Chronic:

  • autoimmune adrenalitis
  • TB or granulomatous disease
  • HIV
  • drugs: ketoconazole / etomidate
  • congenital adrenal hyperplasia
  • adrenoleukodysplasia
  • Addison’s
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13
Q

What is adrenoleukodysplasia?

A

X linked recessive with 2 phenotypes:

1) Cerebral ALD:
- childhood presentation
- dementia, blindness and quadriplegia

2) Adrenomyeloneuropathy
- spasticity and distal polyneuropathy
- young men

To diagnosed: elevated very long chain fatty acids

** screen ANY young boy/man with adrenal insufficiency

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14
Q

Features of glucocorticoid deficiency?

A

Fatigue, lethargy, weight loss and anorexia
Myalgias and joint pains
Fevers
Hypotension

Normocytic anaemia
Lymphocytosis
Eosinophilia

Hypoglycaemia
Slightly elevated TSH (loss of feedback inhibition)
Hyponatraemia (loss of feedback inhibition of vasopressin release)

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15
Q

Features of mineralocorticoid deficiency?

A

Abdominal pain, nausea and vomiting
Dizziness
Postural hypotension

Elevated Cr
Elevated K
Hyponatraemia

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16
Q

What are the skin changes in adrenal insufficiency?

A

PRMIARY: Pigmentation due to excess ACTH melanocytes

But in SECONDARY adrenal insufficiency the skin is PALE due to lack of ACTH

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17
Q

Screening and diagnosis of adrenal insufficiency?

A

Screen with morning cortisol level

Diagnose with short synacthen test

Gold standard is insulin tolerance test

  • contraindicated in epilepsy or IHD
  • only interpretable if hypoglycaemia is induced
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18
Q

Once the adrenals are found to be insufficient, how do you differentiate between primary and secondary?

A

Plasma ACTH:

if HIGH --> primary adrenal insufficiency
Should also get:
- elevated renin
- decreased aldosterone
- decreased serum DHEAS
if NORMAL or LOW --> secondary adrenal insufficiency
Should also get:
- normal renin
- normal aldosterone
- decreased DHEAS
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19
Q

If a diagnosis of PRIMARY adrenal insufficiency is made with short synacthen test and HIGH ACTH…what is the next step?

A

Do adrenal autoantibodies, thyroid studies, look for evidence of vitiligo and premature ovarian failure

If above are negative then:

  • in males look for very long chain fatty acids
  • CT adrenal imaging
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20
Q

If a diagnosis of SECONDARY adrenal insufficiency is made with short synacthen test and LOW/NORMAL ACTH…what is the next step?

A

MRI pituitary to measure pituitary hormones

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21
Q

What drugs can cause adrenal insufficiency?

A

by INHIBITING CORTICAL BIOSYNTHESIS:

  • etomidate
  • ketoconazole
  • fluconazole
  • metyrapone
  • mititane

by INCREASING METABOLISM OF CORTISOL AND SYNTHETIC GLUCOCORTICOIDS:

  • phenytoin
  • barbituitates
  • rifampicin
  • mititane

by SUPPRESSING CRH OR ACTH

  • glucocorticoids
  • megestrol acetate
  • opioids

HEPARIN: by HITS is a risk for bilateral adrenal haemorrhage

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22
Q

Etomidate causes adrenal insufficiency how?

A

by INHIBITING CORTICAL BIOSYNTHESIS:

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23
Q

Phenytoin causes adrenal insufficiency how?

A

by INCREASING METABOLISM OF CORTISOL AND SYNTHETIC GLUCOCORTICOIDS:

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24
Q

Glucocorticoids causes adrenal insufficiency how?

A

by SUPPRESSING CRH OR ACTH

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25
Q

Heparin causes adrenal insufficiency how?

A

HEPARIN: by HITS is a risk for bilateral adrenal haemorrhage

26
Q

Ketoconazole causes adrenal insufficiency how?

A

by INHIBITING CORTICAL BIOSYNTHESIS:

27
Q

Fluconazole causes adrenal insufficiency how?

A

by INHIBITING CORTICAL BIOSYNTHESIS:

28
Q

Barbituates causes adrenal insufficiency how?

A

by INCREASING METABOLISM OF CORTISOL AND SYNTHETIC GLUCOCORTICOIDS:

29
Q

Opioids causes adrenal insufficiency how?

A

by SUPPRESSING CRH OR ACTH

30
Q

Mititane causes adrenal insufficiency how?

A

by INHIBITING CORTICAL BIOSYNTHESIS:
and
by INCREASING METABOLISM OF CORTISOL AND SYNTHETIC GLUCOCORTICOIDS:

31
Q

Megestrol acetate causes adrenal insufficiency how?

A

by SUPPRESSING CRH OR ACTH

32
Q

Rifampicin causes adrenal insufficiency how?

A

by INCREASING METABOLISM OF CORTISOL AND SYNTHETIC GLUCOCORTICOIDS:

33
Q

Metyrapone causes adrenal insufficiency how?

A

by INHIBITING CORTICAL BIOSYNTHESIS:

34
Q

What are the equivalences of steroids?

A 
160mg cortisone acetate
100mg hydrocortisone
25mg prednisone
20mg prednisolone
2.5mg dexamethasone
35
Q

Causes of LOW renin HIGH aldosterone?

A

Primary aldosteronism

  • bilateral adrenal hyperplasia
  • aldosterone producing adenoma (Conns)
  • familial hyperaldosteronism
  • pure aldosterone secreting carcinoma

** Bartter and Gitelman have high renin and high aldosterone but have HYPOTENSION/NORMOTENSION

36
Q

Causes of HIGH renin and LOW aldosterone?

A

Secondary aldosteronism

  • renal artery stenosis
  • diuretics
  • renin secreting tumour
37
Q

Causes of LOW renin LOW aldosterone?

A

Apparent mineralocorticoid excess

  • exogenous mineralocorticoid
  • cushings syndrome
  • liquoriche
  • congenital adrenal hyeprplasia or 11beta-HSD2 defieincy
  • Liddles Syndrome
38
Q

What medications impact renin levels?

A

Renin increased by ACEi and diuretics

Renin decreased by beta blockers and CCBs

39
Q

Why is it important to have a normal K level when measuring aldosterone?

A

Hypokalaemia causes a falsely normal aldosterone level

40
Q

If CT adrenals done to investigate hyperaldosteronism, what is management of a unilateral tumour?

A

If <40yrs: adrenalectomy

If >40yrs: ? incidentaloma –> needs adrenal vein sampling

41
Q

If CT adrenals done to investigate hyperaldosteronism what is the next diagnostic step if there is no visualised tumour?

A

Adrenal vein sampling.
Lateralisation if aldosterone:cortisol is >2 x on one side

If lateralisation then do adrenalectomy
If no lateralisation then medical treatment with spironolactone or amiloride

42
Q

What is the hormonal dysfunction that results from congenital adrenal hyperplasia?

A

group of autosomal recessive disorders
affect adrenal steroid biosynthesis

in response to resultant low cortisol levels the anterior pituitary secretes high levels of ACTH

ACTH stimulates the production of adrenal androgens that may virilize a female infant

43
Q

What are the possible types of congenital adrenal hyperplasia?

A

21-hydroxylase deficiency (90%)
–> gene is CYP21A2

11-beta hydroxylase deficiency (5%)
–> gene is CYP11B1

17-hydroxylase deficiency (very rare)
– gene is CYP17A1

44
Q

Gene and features of 21-hydroxylase deficiency features

A

gene is CYP21A2

virilisation of female genitalia
precocious puberty in males
60-70% of patients have a salt-losing crisis at 1-3 wks of age

45
Q

Gene and features of 11-beta hydroxylase deficiency

A

gene is CYP11B1

virilisation of female genitalia
precocious puberty in males
hypertension
hypokalaemia

46
Q

Gene and features of 17-hydroxylase deficiency features

A

gene is CYP17A1

non-virilising in females
inter-sex in boys
hypertension

47
Q

Indications for surgery for adrenal incidentaloma

A

Size >6cm and/or imaging characteristics suggestive of malignancy

Increased size

Functioning tumour

Pheochromocytoma

48
Q

Which corticosteroid has:
MINIMAL glucocorticoid activity
VERY HIGH mineralocorticoid activity

A

Fludrocortisone

49
Q

Which corticosteroid has:
Glucocorticoid activity
HIGH mineralocorticoid activity

A

Hydrocortisone

50
Q

Which corticosteroid has:
PREDOMINANT glucocorticoid activity
LOW mineralocorticoid activity

A

Prednisolone

51
Q

Which corticosteroid has:
VERY HIGH glucocorticoid activity
MINIMAL mineralocorticoid activity

A

Dexmethasone

Betamethasone

52
Q

What steroid activity does it have:

Fludrocortisone

A

MINIMAL glucocorticoid activity

VERY HIGH mineralocorticoid activity

53
Q

What steroid activity does it have:

Hydrocortisone

A

Glucocorticoid activity

HIGH mineralocorticoid activity

54
Q

What steroid activity does it have:

Prednisolone

A

PREDOMINANT glucocorticoid activity

LOW mineralocorticoid activity

55
Q

What steroid activity does it have:
Dexamethasone
Betmethasone

A

VERY HIGH glucocorticoid activity

MINIMAL mineralocorticoid activity

56
Q

What is Waterhouse-Friderichsen syndrome

A

Adrenal gland failure secondary to previous adrenal haemorrhage that was caused by severe bacterial infection.

57
Q

Causes of Waterhouse-Friderichsen syndrome

A

meningococcus

Haemophilus influenzae

Pseudomonas aeruginosa

Escherichia coli

Streptococcus pneumoniae

58
Q

In Adrenocortical Carcinoma

  • genetics?
  • Prognostic marker?
  • Treatment?
A

GENETICS:

  • somatic mutations in tp53 (25%)
  • germline mutation in tp53 in Li Fraumeni Syndrome

IGF-2 overexpression in 90%

Most important prognostic marker is Ki67 proliferative index

  • if <10% = slow-mod growth
  • if >10% = POOR prognosis

Treat:

  • surgery
  • Mitotane: need to give steroid as well as mitotane disrupts cortisol synthesis, so need >2x normal insufficiency doses
59
Q

What to be aware of if giving mitotane?

A

need to give steroid as well as mitotane disrupts cortisol synthesis, so need >2x normal insufficiency doses

60
Q

What HLA class are associated with Addison’s Disease?

A

HLA DR3/4 and DQ2/8

61
Q

What antibodies are seen in Addison’s Disease?

A

Anti-21-hydroxylase (in 50-80%)

62
Q

Factors that increase and decrease plasma corticosteroid-binding globulin (CBG)

A

INCREASE:

  • pregnancy
  • oestrogen administration
  • hyperthyroid
  • inflammation/acute illness

DECREASE:

  • protein deficiency
  • diminished synthetic capability

RACP Written 2018 (167 decks)

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