Endocrinology - Adrenal Disorders

Question 1

Differentiate between different types of adrenal insufficiency

Answer 1

Primary
- decreased production of glucocorticoid from adrenal cortex
- Addison’
- TB, HIV
- congenital adrenal hypoplasia
Secondary
- Decreased ACTH from pituitary resulting in decreased glucocorticoid production from adrenal cortex
- hypopituitarism
- pituitary adenoma or stalk trauma
- suppression of ACTH from withdrawal of exogenous steroids
Tertiary
- decreased CRH from hypothalamus resulting in decreased ACTH

Question 2

Discuss the presentation, diagnosis and treatment of chronic adrenal insufficiency

Answer 2

Presentation
- weakness, weight loss
- N/V
- hypotension and postural dizziness
- visual field defect if pituitary adenoma
- hyponatremia
- primary: dark skin and mucosa from ACTH, metabolic acidosis
- secondary: hypothyroidism and hypogonadism
Diagnosis
- low plasma cortisol at 8am or low plasma cortisol despite ACTH stimulation
- primary high ACTH and low cortisol and persistent low cortisol despite stimulation
- secondary/tertiary low ACTH and cortisol, increased cortisol in response to ACTH stimulation
Management
- hydrocortisone 15-20mg daily divided BID-TID
- increase 2-3x if mod-severe illness
- large dose 150-300mg IV daily divided TID for major stress (surgery, trauma)
- medical alert bracelet for IM hydrocortisone if suffer major stress

Question 3

Discuss the presentation and management of adrenal crisis

Answer 3

- inappropriate cortisol production in response to stress
Presentation
- N/V
- confusion
- shock/hypotension
- hypoglycemia
Management
- obtain blood sample for ACTH, cortisol and electrolyte
- Immediate:
      - IV NS 2-3L bolus
      - D5W if hypoglycemic
      - hydrocortisone 50-100mg IV Q6-8H for 24hr then taper

Question 4

Discuss the pathophysiology, presentation, investigation and management of Paget Disease of Bone

Answer 4

Pathophysiology
- Increased osteoclast activity leading to increased bone resorption -> osteoblast activity increase to produce new bone that is structurally abnormal and fragile
Presentation
- Asymptomatic (elevated ALP)
- Severe bone pain (pelvis, femur, skull, tibia, vertebrae)
- skeletal deformities: bowed tibias, kyposis, frequent fractures
- increased warmth over bone
- high output CHF
- hypercalcemia with immobilization
Investigation
- Increase ALP with normal GGT
- Normal of increase Ca, normal PO4
- Bones are denser and expanding with cortical thickening
- Initial may be destructive and radiolucent
- Increased fissuring
Management
- weigthbearing
- adequate Ca and Vit D to prevent secondary hyperparathyroidism
- Treat with symptomatic, ALP >3x normal or planned surgery
- Alendronate
- Zoledronic acid
- Calcitonin