22. Adrenal insufficiency Flashcards Preview

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Flashcards in 22. Adrenal insufficiency Deck (49):
1

Definition

inability of adrenal glands to generate enough glucocorticoids +/- mineralcorticoids for the body's needs

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Symptoms

1. weakness
2. fatigue
3. orthostatic hypotension
4. muscle aches
5. weight loss
6. GI disturbances
7. sugar and salt craving

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Diagnosis

1. measurement of serum electrolytes
2. morninf/ random serum cortisol ACTH
3. response to ACTH stimulation test
4. metyraptone stimulation stest

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metyraptone mechanism of action

it blocks the last step of cortisol synthesis 11- deoxycortisol --> cortisol

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metyraptone stimulation test - results

normal decreased cortisol and compensatory increased ACTH and 11- deoxycortisol
In 1ry adrenal insufficiency : ACTH is increased nut 11- deoxycortisol remainsdecreased
In 2ry and 3ry, both ACTH and 11-deoxycortisol remain decreased after test

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11- deoxycortisol ---> cortisol is inhibited by

metyraptone

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Adrenal insufficiency is divided to

1. primary
2. secondary
3. tertiary

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tertiary adrenal insufficiency seen in ...

seen in patients with chronic exogenous steroids use precipitated by abrupt withdrawal of exogenous steroids

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Tertiary adrenal insufficiency is precipitated by

abrupt of exogenous steroids

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tertiary adrenal insufficiency - aldosterone

unaffected

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secondary adrenal insufficiency

seen with decreased pituitary ACTH production

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primary adrenal insufficiency

deficiency of ALDOSTERONE AND CORTISOL production due to loss of gland function

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primary adrenal insufficiency - symptoms and findings

1. hypotension ( hyponatremic volume contraction)
2. hyperkalemia
3. metabolic acidosis
4. skin and mucosal hyperpegmentation

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primary adrenal insufficiency - hypotension

hyponatremic volume contraction

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primary adrenal insufficiency - skin and mucosal hyperpigmentation is due to

MSH, a byproduct of increased ACTH production from pro-opiomelanocortin

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primary adrenal insufficiency is divided to

1. acute
2. chronic

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chronic primary adrenal insufficiency is also called

Addison disease

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Addison disease

chronic primary adrenal insufficiency

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Addisson disease is due to ( and MCC)

adrenal atrophy or destruction disease ( eg. autoimmune, TB, metastasis
MC in western world --> autoimmune
MC in developing world --> TB

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acute primary adrenal insufficiency - characterostoc and example

sudden onset ( eg due to massive hemorrhage)

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acute primary adrenal insufficiency - may present with

shock in acute adrenal crisis

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primary vs secondary adrenal insufficiency ( according symptoms and signs)

- secondary has no skin / mucosal hyperpigmentation
- secondary has no hyperkalemia

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secondary adrenal insuficiency - hyperkalemia ( why )

secondary has no hyprekalemia
ALDOSTERONE SYNTHESIS IS PRESERVED

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autoimmune primary chronic adrenal insufficiency is associated with

AUTOIMMUNE POLYGLANDULAR SYNDROMES

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Waterhouse - Friderichsen syndrome is

acute primary adrenal insufficiency due

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Waterhous - Friderichsen is due to

to adrenal hemorrhage ( bleeding into the glands) associated with septicemia, DIC, endotoxic shock

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hyperaldosterinism - divided to

primary and secondary

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primary hyperaldosterinism is caused by

1. idiopathic adrenal hyperplasia
2. aldosterone secreting adrenal adenoma ( Cohn syndrome)

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Cohn syndrome

aldosterone secreting adrenal adenoma

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primary hyperaldosterinism - symptoms and signs ( and labs)

1. hypertension
2. hypokalemia
3. metabolic alkalosis
4. low plasma renin

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primary hyperaldosterinism may be divided

bilateral or unilateral

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primary hyperaldosterinism - sodium / edema ( and why )

normal ( and no edema) due to aldosterine escape mechanism

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primary hyperaldosterinism - edema ( and why)

no due to normal sodium ( aldosterine escape mechanism)

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aldosterine escape mechanism

increased sodium reasbsorption causes increased H2O reabsorption as well

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secondary hyperaldosterinism - treatment

spirolactone

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secondary hyperldosteronism - due to

1. renal artery stenosis
2. juxtaglomerular cell tumor

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secondary hyperaldosterinism - pathophysiology

renal perception of low intravascular volume in an overactive renin - angiotensin system

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secondary hyperaldosterinism is associated with

high plasma renin

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A patient is thought to have adrenal insufficiency. What symptoms do you expect? What labs would you order?

Weakness, hypotension, fatigue, muscle aches, weight loss, sugar and/or salt cravings; morning/random cortisol and ACTH, ACTH stimulation

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Your preceptor asks you to order a metyrapone stimulation test for a patient with suspected adrenal insufficiency (AI). Why?

Metyrapone blocks cortisol synthesis, normally ACTH rises and cortisol falls after metyrapone administration, and ACTH remains low in AI

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A septic young boy with petechiae, hypotension, and hyperkalemia goes into DIC and endotoxic shock. What is the treatment for this?

In Waterhouse-Friderichsen syndrome—acute primary adrenal insufficiency—ceftriaxone is used to treat the Neisseria meningitidis

42

A woman with lupus would like to discontinue her medications,which include exogenous steroids. Why should you taper off the corticosteroids?

Abrupt discontinuation can lead to adrenal insufficiency (tertiary)

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Why is primary adrenal insufficiency marked by skin and mucosal findings?

Increased MSH (melanocyte-stimulating hormone) from pro-opiomelanocortin causes pigmentation, a result of increased ACTH

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One of your patients has Addison disease. What would pathologic study of his adrenal gland show?

Adrenal Atrophy (and Absence of hormone production) involving All three cortical layers (sparing the medulla)

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What acid-base status is expected in a young man with primary adrenal insufficiency (AI)?

Patients with Addison disease are acidotic (metabolic) (autoimmune disease is the most common cause of primary chronic AI)

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A patient with meningococcal septicemia becomes hypotensive, with disseminated intravascular coagulation. What is the likely diagnosis?

Waterhouse-Friderichsen syndrome, or acute primary adrenal insufficiency caused by adrenal hemorrhage

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What is, by far, the most common cause of tertiary adrenal insufficiency?

Abrupt discontinuation of chronic exogenous corticosteroids

48

A man with SLE exhibits skin and mucosal hyperpigmentation. Labs show high K+ and metabolic acidosis. Most likely disease mechanism?

In light of the history of SLE, this is likely chronic autoimmune destruction of his adrenal glands (Addison disease)

49

A man from Africa has night sweats and fevers. He is hypotensive and hyperkalemic. Metyrapone stimulation does not increase ACTH. Diagnosis?

Seeding of his adrenal gland by tuberculosis, resulting in a primary adrenal insufficiency