Adrenal disease 290921

Question 1

• 31yo, profound fatigue, acutely unwell for a few days, vomiting
• Test results:
o Na = 125 K = 6.5 U = 10 Glucose = 2.9mM
o FT4 = <5nM TSH = >50mU/L

Answer 1

• TSH and T4 measurements  Primary hypothyroidism (or thyroid failure)

• Unusual U&Es (hyponatraemia and hyperkalaemia)  mineralocorticoid deficiency  Addison’s disease
• Hypoglycaemia  glucocorticoid deficiency

addisons + primary hypothyroidism = schmidt’s syndrome

Question 2

what is schmidt’s syndrome

Answer 2

o AKA: Polyglandular autoimmune syndrome type II

o Antibodies against the thyroid and adrenal glands

Question 3

how to measure addisons

Answer 3

o 1) Measure cortisol and ACTH at start
o 2) 250ug ACTH, IM
o 3) Check cortisol at 30 and 60 minutes

Question 4

TB patients addisons

Answer 4

TB invades adrenals

Question 5

management addisons

Answer 5

o Management = IV 0.9% saline (1L/hour), IV hydrocortisone

Question 6

Test for Phaeochromocytoma

Answer 6

urinary catecholamines

Question 7

Emergency treatment for phaeo

Answer 7

alpha blockade, phenoxybenzamine, then beta blockers, then surgery (very careful surgery as if you touch it the alpha receptors could be stimulated)

Question 8

32 yo HTN, adrenal mass

Answer 8

conn’s, cushings, phaeo

Question 9

Genetic links of phaeo

Answer 9

MEN2, Von hippel Lindau syndrome, neurofibromatosis type 1

Question 10

• 33yo, HTN
• Urea and electrolytes:
o Na = 147 K = 2.8 U = 4.0 Glucose = 4.0mM
o Plasma aldosterone raised Plasma renin suppressed

Answer 10

• Primary hyperaldosteronism / Conn’s Syndrome

o Adrenal gland autonomously secretes aldosterone  HTN  supress renin production at JGA

Question 11

• 34yo, obese woman, T2DM, HTN, bruising

• Urea and electrolytes:
o Na = 146 K = 2.9 U = 4.0 Glucose = 14.0mM
o Aldosterone = <75 (low) Renin = low

Answer 11

cushing’s

Question 12

Cushing’s diagnosis test

Answer 12

DEX suppression test

Question 13

Commonest cause of cushings syndrome

Answer 13

oral steroids
if NOT on drugs 85% cause is pituitary dependent cushing’s disease
5% ectopic ACTH
10% adrenal adenoma

Question 14

psuedoCushing’s

Answer 14

obesity can change metabolism of cortisol  condition mimicking Cushing’s (pseudo-Cushing’s syndrome)

Question 15

How is the cause of cushings confirmed

Answer 15

Pituitary SAMPLING
A catheter is fed into the jugular vein
 Distinguishes pituitary dependant from ectopic ACTH

Question 16

Why don’t we do high dose dex suppression test anymore

Answer 16

o We don’t do the high-dose test anymore because 85% are pituitary-dependant without the test and so doing a high-dose test is less accurate (false +ve = 20%) than guessing and so it is not useful
 Equally, pituitary MRIs with gadolinium enhancement is not that useful but can be definitive