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Endocrine > Hypercortisolism > Flashcards

Hypercortisolism Flashcards

1
Q

What is the definition of Cushing’s syndrome?

A

Complex resulting from prolonged supraphysiological concentrations of glucocorticoids

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2
Q

What is the width of the abdominal striae?

A

Greater than 1 cm

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3
Q

What causes the thin skin and poor wound healing with Cushing’s?

A

Inhibition of fibroblasts

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4
Q

What muscles are particularly weak with Cushing’?

A

Proximal muscles

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5
Q

What are the two causes of insulin resistance with Cushing’s?

A

DM2 or impaired glucose tolerance

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6
Q

What are the supraclavicular findings of Cushing’s disease?

A

Fullness

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7
Q

What are the three endogenous causes of Cushing’s?

A

Primary (adrenal issue)
Secondary (increased ACTH)
Tertiary (increased CRH)

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8
Q

What is the most common cause of Cushing’s?

A

Iatrogenic exogenous steroid administration

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9
Q

ACTH independent cause of Cushing’s = ?

A

Exogenous or primary

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10
Q

What are the ACTH dependent causes of Cushing’s?

A

Pituitary or hypothalamic causes

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11
Q

What is the most common cause of ACTH dependent Cushing’s?

A

Pituitary microadenoma (true Cushing’s disease) from a mutated corticotroph cell

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12
Q

What are the common causes of ectopic ACTH production?

A

Bronchial or thymic carcinoid

SCLC

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13
Q

What are the ACTH levels of ectopic production of ACTH relative to Cushing’s disease?

A

5-10x greater than pituitary ACTH overproduction

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14
Q

What other findings are common with ectopic ACTH production? (2)

A
  • Hirsutism from adrenal androgen production

- hyperpigmentation from ACTH precursor

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15
Q

True or false: ectopically producing ACTH tumors cause hyperpigmentation

A

True

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16
Q

What are the two breakdown products of POMC?

A

ACTH

MSH

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17
Q

Are ectopic ACTh secreting tumors fast or slow onset?

A

Fast

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18
Q

Which are more common: adrenal adenoma or carcinomas? Are these usually unilateral, or bilateral?

A

Unilateral adenoma

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19
Q

What are the two major etiologies of bilateral adrenal disease?

A

Micronodular hyperplasia

Macronodular hyperplasia

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20
Q

What are the three major steps of diagnosing Cushing’s?

A
  1. Confirm hypercortisolemia
  2. Determine subtype
  3. Localize source of overproduction
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21
Q

Why is testing for Cushing’s done as an outpatient?

A

Increased stress in the hospital may give false positives

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22
Q

What are the three major tests that can be done to assess for hypercortisolemia?

A
  • 24 hour urinary free cortisol excretion
  • 2300 salivary or serum cort
  • Low dose dexamethasone suppression test
23
Q

How is the low dose dexamethasone test performed?

A

Give Cort at 2300, return at 0800 to check ACTH levels

24
Q

What are the ranges for normal, borderline, and high 24 hr urinary cortisol collection concentrations?

A

Less than 50 mcg: unlikely
50-150 = borderline
More than 150 = likely

25
Q

True or false: a normal 24 urine collection test usually rules out Cushings

A

False– may have a secretory type Cushing’s

26
Q

What, besides Cushing’s, will cause an abnormally elevated 24 hours UFC?

A

Pseudo Cushing’s

27
Q

How can the 24 hour urine cortisol test be made more accurate?

A

done x4 over a month

28
Q

What is pseudo-cushing’s? Causes?

A

Underlying issue that stimulates that HPA axis

  • EtOH-ism
  • Depression
  • Severe stress/surgery/infection
29
Q

What is the medication that causes a decreased clearance of cortisol?

A

Carbamazepine

30
Q

What is the best test to do on patients who may have pseudo-Cushing’s?

A

Overnight low-dose Dexamethasone suppression test

31
Q

Why is the midnight salivary cortisol testing useful to diagnose Cushing’s?

A

Should be very low at this time, but Cushing’s will disrupt the normal diurinal pattern

32
Q

What are the ranges of the midnight salivary test for Cushing’s?

A
  • less than 5 mcg = no
  • 5-7.5 mcg = indeterminant
  • More than 7.5 = likely cushing
33
Q

What are the ranges of serum cortisol for the low dose dexamethasone test?

A

Normal = less than 2 mcg/dL
Indeterminant = 3-10 mcg/dL
More than 10 = Likely Cushing’s

34
Q

Hypercortisolemia + low ACTH = what?

A

Adrenal pathology

35
Q

High ACTH + high cortisol levels = ?

A

Pituitary, hypothalamic, or ectopic pathology

36
Q

What is the best way to assess for a pituitary problem causing hypercortisolemia? Adrenal? Ectopic?

A
  • Pituitary = MRI the head
  • Adrenal = CT the abo
  • Ectopic = CT the chest
37
Q

What is the treatment for adrenocortical adenomas? What are the complications that can arise from this?

A
  • Surgical resection

- Atrophy of contralateral gland or pituitary corticotroph atrophy, leading to hypocortisolism

38
Q

How malignant is adrenal carcinoma? Prognosis? Treatment?

A

Highly malignant
Poor
Surgical debulking, RT, non-specific chemo

39
Q

What are the three etiologies of ACTH dependent Cushing’s?

A

Pituitary, Hypothalamic, or ectopic tumor secreting ACTH

40
Q

What are the two tests that can be performed to determine if a small pituitary mass is secreting ACTH?

A
  • Inferior petrosal sinus sampling

- High dose dexamethasone test

41
Q

What is the dose for low and high dose dexamethasone?

A

1 vs 8 mg

42
Q

What is the role of the high dose dexamethasone test?

A

Pituitary will show partial suppression of ACTH, but ectopic will NOT

43
Q

What is done with inferior petrosal sinus sampling?

A

Give CRH

Comparing the concentration of ACTH in the sinus vs the concentration of ACTH in the periphery–helps localize source of ACTH

44
Q

What is the anatomic site of where the pituitary drains?

A

Petrosal sinus

45
Q

What is the outcome of the Inferior pituitary sinus sampling test that will identify it as a pituitary source?

A

If IPS : P ratio is more than 2:1, then it is a pituitary source

46
Q

What are the options for treating Cushing’s disease?

A

Irradiation
Surgery
Adrenal surgery
Drug therapy

47
Q

What is the indication of performing bilateral adrenalectomies in patients with an ACTH secreting pituitary adenoma?

A

If cannot remove the pituitary problem, then remove the source of cortisol

48
Q

What is the mortality rate of pituitary surgery?

A

1%

49
Q

What are the complications of pituitary surgery?

A

Anterior pituitary deficits

DI from post op swelling

50
Q

What are the downsides of stereotactic radiosurgery on the pituitary? (2)

A

Slow therapeutic response

Post radiation panhypopituitarism

51
Q

What is the use and MOA of aminoglutethimide?

A

Anticonvulsant that blocks the conversion of cholesterol to pregnenolone,

Leads to Decreased cortisol, aldosterone, and androgens

52
Q

What is the use and MOA of ketoconazole?

A

Antifungal used to lock 11 beta hydroxylase to decrease cortisol, aldosterone, DHEA

53
Q

What is the use and MOA of mitotane?

A

Blocks 11 beta hydroxylase

Decreases all cortical adrenal stuffz

54
Q

What is the treatment for an ectopic site of ACTH production that is not well localized?

A

RT/chemo
Bilateral adrenal adrenalectomy
Meds

Endocrine (32 decks)

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