Lecture 2: Adrenal Flashcards

1
Q

Describe the difference between the short-term and long-term stress response in terms of the HPA axis and the adrenal cortex.

A
  • Short-term causes stimulation of the adrenal medulla to ↑ release of catecholamine (NE and epinephrine)
  • Long-term causes stimulation of the adrenal cortex and ↑ release of mineralocorticoids and glucocorticoids
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2
Q

What are the effects of angiotensin II on the adrenal cortex and pituitary gland?

A
  • Adrenal cortex: stimulates secretion of aldosterone
  • Posterior pituitary: stimulates the secretion of ADH
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3
Q

What are the 3 mainstays of treatment in an infant in crisis due to congenital adrenal hyperplasia (21-hydroxylase deficiency)?

A
  • Hydrocortisone (IV or IM)
  • Fluids/glucose (IV)
  • Management of hyperkalemia: get K+ levels ↓
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4
Q

Summarize the purpose of mandatory newborn screening, which 7 major classes of disorders are screened for?

A
  • Amino acid disorders
  • Endocrine disorders
  • Fatty acid oxidation disorders
  • Hemoglobin disorders
  • Lysosomal storage disorders
  • Organic acid conditions
  • Others: CF, hearling loss, classic galoctosemia, congenital HD, SCID
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5
Q

What is the most common cause of adrenal destruction responsible for primary adrenal insufficiency (Addison disease) in the US?

A

Autoimmune

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6
Q

Which autoimmune causes of adrenal destruction are associated with neurological deterioration which may mimic multiple sclerosis?

A

Adrenoleukodystrophy and adrenomyeloneuropathy

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7
Q

What is the inheritance pattern and what is seen with familial glucocorticoid deficiency (ACTH, cortisol, and mineralocorticoid levels)?

A
  • Autosomal recessive
  • ACTH resistance due to mutations in the adrenal ACTH receptors –> isolated cortisol deficiency
  • ACTH causes skin pigmentation
  • Mineralocorticoid production is always normal
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8
Q

Which disease of adrenal dysgenesis is associated with hypogonadotropic hypogonadism, myopathy, and high-frequency hearing loss?

A

Congenital adrenal HYPOplasia (x-linked) = absence of adrenal cortex

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9
Q

What is the most common cause of impaired steroidognesis leading to primary adrenal insufficiency; what are the levels of adrenal hormones like?

A
  • 21-hydroxylase deficiency
  • Deficiency of aldosterone = salt-wasting
  • Deficiency of cortisol
  • Excessive androgens (virilization of females)
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10
Q

Nearly all patients with primary adrenal insufficiency complain of what signs/sx’s?

A
  • Fatigue + reduced stamina + weakness + anorexia + weight loss
  • Skin hyperpigmentation
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11
Q

What is the serum Na+, K+, glucose, and calcium like in primary adrenal insufficiency?

A
  • Low serum Na+
  • High serum K+
  • Fasting HYPOglycemia
  • HYPERcalcemia may be present (↓ renal filtration)
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12
Q

What is the confirmatory test for primary adrenal insufficiency?

A

- Cosyntropin (synthetic ACTH) stimulation test

- If cortisol levels do no respond after 45 mins., confirms

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13
Q

Which serum markers can be used to confirm autoimmun Addison disase and which is required for diagnosis of 21-hydroxylase deficiency?

A
  • Serum antibodies to 21-hydroxylase confirm dx of autoimmune Addison disease
  • ↑ serum levels of 17-OH progresterone are required for diagnosis
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14
Q

What is the treatment for primary adrenal insufficiency (Addison disease)?

A
  • Glucocorticoid replacement therapy: hydrocortisone, predisone, prednisolone
  • Mineralocorticoid replacement therapy: fludrocortison acetate (Na+ sparing)
  • DHEA: given to some post-menopausal women (libido, done density, hormonal balance)
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15
Q

List 5 labs which can be ordered to help diagnose acute adrenal crisis?

A
  • ACTH (cosyntropin) stimulation test
  • Cortisol level
  • Blood sugar
  • Serum K+
  • Serum Na+
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16
Q

If you are dealing with an infant in the first several weeks of life with suspected acute adrenal crisis, what lab needs to be drawn?

A

17-OH-progesterone level; must rule out 21-hydroxyase deficiency

17
Q

What are the 3 components of treatment for acute adrenal crisis?

A
  • Hydrocortisone
  • Fluids/glucose
  • Treat HYPERkalemia if needed
18
Q

Low serum ACTH in the setting of low serum cortisol is indicative of what type of adrenal abnormality?

A

Secondary adrenal insufficiency

19
Q

What are 3 possible causes of ACTH-dependent Cushing Syndrome?

A
  • Exogenous ACTH use
  • Cushing disease (ACTH-secreting pituitary adenoma)
  • Ectopic ACTH syndrome –> small cell carcinoma of lung
20
Q

What are some of the possible causes of ACTH-independent Cushing Syndrome?

A
  • Exogenous corticosteroid use (MOST COMMON)
  • Adrenocortical tumor
  • Bilateral primary adrenocortical hyperplasia: PPNAD, Carney complex, massive macronodular adrenal hyperplasia, McCune-Albright syndrome
21
Q

What is seen in McCune-Albright Syndrome?

A
  • Polyostotic fibrous dysplasia
  • Café-au-lait spots
  • Endocrine hyperfunction from mutliple organs —> bilateral primary adrenocortical hyperplasia
22
Q

All (even normotensive) patients with an adrenal incidentaloma require testing for what?

A

Pheochromocytoma w/ plasma fractionated free metanephrines

23
Q

What is the most common cause of refractory HTN in youths and middle-aged adults?

A

Primary aldosteronism (hyperaldosteronism)

24
Q

Conn sydrome is primary hyperaldosteronism secondary to what?

A

Unilateral aldosterone-producing adrenal adenoma

25
Q

40% of pt’s w/ primary hyperaldosteronism (Conn Syndrome) have a mutation in a gene encoding what?

A

K+ channel

26
Q

What are the signs and sx’s of primary hyperaldosteronism?

A
  • HTN = moderate to severe; some only diastolic HTN
  • HYPOkalemia –> muscle weakness, parasthesias w/ tetany, HA, polyuria and polydipsia
27
Q

Which acid-base disorder is commonly seen with primary hyperaldosteronism?

A

Metabolic alkalosis (proton loss, H+ w/ K+)

28
Q

All patients with biochemically confirmed primary aldosteronism require what type of imaging?

A

Thin-section CT scanof adrenal to screen foradrenal carcinoma(althoughrare)

29
Q

How does the secretory products differ between pheochromocytomas and paragangliomas?

A
  • Pheochromocytomas secrete BOTH epi and NE
  • Paragangliomas secrete NE or are non-secretory
30
Q

What is the inheritance pattern of Von Hippel-Lindau disease type 2?

A

Autosomal Dominant

31
Q

What are some of the underlying abnormalities associated with Von Hippel-Lindau disease type 2?

A
  • 20% develop pheochromocytomas (which secrete only NE)
  • Hemangiomas of retina, cerebellum, brainstem, and SC
  • Hyperthyroidism
  • Pancreatic cysts + Renal cyts
  • Endolymphatic sac tumors
  • Cystadenomas of the adnexa or epididymis
  • Pancreatic neuroendocrine tumors
  • Adenomas + Carcinomas
32
Q

What is the single most sensitive test for secretory pheochromocytomas and paragangliomas?

A

Plasma fractionated free metanephrines

33
Q

If the abdomen becomes “seeded” during surgery for a pheochromocytomas this can result in multifocal intra-abdominal tumors known as what?

A

Pheochromocytomatosis

34
Q

Will surgical histopathology for pheochromocytoma and paragangliomas determine if a tumor is malignant?

A
  • NO
  • All pheo’s and paragangliomas must be approached as possibly malignant
  • Follow-up has to be lifelong