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Flashcards in Adrenal Deck (99):
1

Where are mineralocorticoids produced?

Zona glomerulosa

2

Where are glucocorticoids produced?

Zona fasciculata
(regulated by ACTH)

3

Where are androgens produced?

Zona reticularis

4

Wehere are catecholamines produced?

Medulla

5

What regulates aldosterone?

Renin-angiotensin system and plasma potassium

6

What does angiotensin II do?

Causes vasoconstriction and stimulates release of aldosterone from adrenals

7

Name a vitamin which is a steroid?

Vitamin D is a steroid

8

Immunological effects of cortisol?

Increases capillary permeability
Increases macrophage activity
Increases inflammatory cytokine production
Increases leucocyte migration

9

Metabolic effects of cortisol?

Increases lipolysis, central redistribution
Increases break down of carbohydrate (increases blood sugar)
Increases proteolysis

10

Circulatory/renal effects of cortisol

Increases cardiac output
Increases blood pressure
Increases renal blood flow and GFR

11

Cortisol effects on bone/connective tissue

Accelerates osteoporosis
Decreases serum calcium
Decreases collagen formation
Decreases wound healing

12

Aldosterone and Na+?

Aldosterone increases reabsorption of Na+

13

21 year old female
‘unwell’ for few months
Weight loss
Amenorrhoea
Acutely unwell over past 48 hours with vomiting and diarrhoea
On examination:
Dark skin
Dehydrated
Hypotensive
Decreased Na Increased K

Addisons

14

Commonest cause of secondary adrenal insufficiency?

Exogenous steroid use
e.g. high dose prednisolone
inhaled corticosteroid
dexamethasone

15

Aldosterone replacement?

Fludrocortisone

16

Cortisol replacement

Hydrocortisone

17

Might you see acne amenhorrea and hypertension in Cushing's?

Yes

18

Main cause of Cushing's?

-Taking too much steroid (= chronic suppression of pituitary ACTH and adrenal atrophy)
Pituitary adenoma
(then ectopic ACTH e.g. in carcinoid/carcinoma)

19

Types of cancer that produced ACTH?

Carcinoid/carcinoma

20

Possible complications of long term steroid and ACTH suppression?

Body is unable to respond to stress (illness/surgery)
Need extra doses of steroid when ill/surgery

21

Hypertension and hypokalaemia?

Could be primary aldosteronism

22

Difference between primary and secondary hyperaldosteronism

Primary hyperaldosteronism = excessive levels of aldosterone independent of renin-angiotensin system
Secondary hyperaldosteronism = excessive levels of aldosteronism because of high renin levels

23

Cardiovascular effects of aldosterone

Altered endothelial function
Increase in ROS and cytokine synthesis
Increased cardiac collagen
Increased blood pressure
Sodium retention
Increased sympathetic outflow

24

Commonest secondary cause of hypertension?

Primary aldosteronism (essential hypertension is most common primary cause)

25

Somebosy presents with hypertension, hypokalaemia and cramps (because of alkalosis) what might they have?

Hyperaldosteronism

26

Con's syndrome

Adrenal adenoma (produces aldosterone)

27

Causes of hyperaldosteronism?

Conns syndrome (adrenal adenoma)
Bilateral adrenal hyperplasia --> MOST COMMON CAUSE (unilateral is rare)

28

KCNJ5 mutations?

May lead to primary aldosteronism
=allows more sodium into cell and depolarisation etc

29

Management of primary aldosteronism?

Surgical
Unilateral laparoscopic adrenalectomy
Only if adrenal adenoma (and excess confirmed in adrenal vein sampling)
Cure of hypokalaemia
Cures hypertension in 30-70% cases
Medical
In bilateral adrenal hyperplasia
Use MR antagonists (spironolactone or eplerenone)

30

CAH

Congenital adrenal hyperplasia
21 a hydroxylase
Autosomal recessive

31

Management of hypercalcemia?

Fluids
Frusemide
Bisphosphonates

32

Where do papillary thyroid cancers occur?

In iodine rich areas

33

Do follicular adenoma and carcinoma share the same architecture?

Yes, difficult to distinguish
Excisional biopsy may be required

34

Which type of thyroid cancer are related with MEN?

Medullary carcinomas are related with MEN
They originate from parathyroid follicular C cells and secrete calcitonin

35

Which type of thyroid cancers originate from parathyroid follicular C cells and secrete calcitonin?

Medullary

36

How do follicular thyroid cancers spread

Via blood

37

Can phaechromoctyoma lead to diabetes?

Yes

38

Most common cause of death in acromegalics?

Cardiovascular disease

39

Is acne common in acromegaly?

Yes

40

Cardiovascular disease seen in acromegaly?

Fibrosis, hypertrophy, carditis
(VALVE DISEASE IS NOT COMMON)

41

Growth in children with Cushing's?

Growth is often arrested due to excess steroid

42

Causes of SIADH?

C, C, C
Chest: pneumonia, TB, carcinoma, abscess
Cranial causes: head injury, intracranial bleed, meningoencephalitis, space occupying lesions
CHLORPROPRAMIDE and other drugs

43

Drugs which could cause gynaecomastia?

Sprionolactone
Methyldopa

44

Visual field loss, sweaty greasy skin, large tongue, difficulty with dentures (because of jaw or something), spade shaped hands. Who am I

Acromegaly

45

Congenital heart disease can cause growth retardation?

Pastest says yes

46

Diabetic nephropathy and death?

Responsible for 25% of diabetic deaths under the age of 30

47

Is diabetic nephropathy commonly associated with coronary artery disease?

yes

48

Drug which you should give to diabetics, can help slow down proteinuria etc

ACE INHIBITOR OMG

49

Amylase levels in diabetic ketoacidosis

Usually raised

50

Hypothyroidism and Down Syndrome?

Hypothyroidism is common in people with Down Syndrome

51

Salt wasting form of CAH

Weight loss, extreme tiredness, dehydration, vomitting

52

Virilising form of CAH

-Recognised at 2-4 years
Early virilisation
Penis enlargement
Growth of hair

53

Non-classical form of CAH

Less severe
Develop sexually at an early age
-Hirsutis
-Acne
-Oligomenorrhea
-Precocious puberty
-Infertility or subfertility

54

Diagnosis of CAH?

Basal or stimulated 17-OH-Progeseterone
Genetic being used more

55

Sources of phaeochromocytoma

Phaechromocytoma in adrenal medulla
(rarely = sympathetic chain --> paraganglioma)

56

Chromaffin cell reaction colour

Chromaffin cells reduce chrome salts to metal chromium resulting in a brown colour reaction

57

Phaechromocytoma symptoms?

Classic triad: sweating, hypertension, headache
Labile hypertension
Postural hypotension
Paroxsymal sweating, headache, pallor, tachycardia
(chromaffin cells reduce chrome salts to metal chromium resulting in a brown colour reaction)
-Try to diagnose Phaechromocytoma! Risks in pregnancy and other risks for everyone relating to arrythmia and ischemia --> could cause death etc
Palpitations
Breathlessness
Constipation
Anxiety/Fear
Weight loss
Hypertension
Postural hypotension in 50% cases
Pallor
Bradycardia and Tachycardia
Pyrexia
Signs of complications
Left ventricular failure
Myocardial necrosis
Stroke
Shock
Paralytic ileus of bowel

58

Differentials for Phaeochromocytoma

Angina
Anxiety
Carcinoid
Thyrotoxicosis
Insulinoma
Menopause
Arrhythmia( eg. SVT)
Migraine
Drug toxicity
Alcohol withdrawal
Pregnancy
Hypoglycaemia
Mastocytosis
Autonomic neuropathy
Factitious

59

Biochemical Abnormalities in Phaeochromocytoma

Hyperglycaemia – adrenaline secreting tumours
May have low potassium level
High haematocrit – i.e. raised Hb concentration
Mild hypercalcaemia
Lactic acidosis – in absence of shock

60

The 10% tumour

Phaeochromocytoma
10% malignant
10% extra-adrenal [probably 20-30%]
10% bilateral
10% associated with hyperglycaemia
10% in children
10% familial (but probably 25%)

61

Hypertension and hyperglycemia?

Consider phaeochromocytoma

62

Diagnosis of Phaeochromocytoma/catecholamine excess

-2 x 24 hour urine catecholamine/metanephrine
-Plasma: ideally at time of symptoms
Identify source of catecholamines:
-MRI
-MIBG
-PET

63

Clinical Syndrome Associations (phaechromocytoma)

Multiple Endocrine Neoplasia II
Von-Hippel-Lindau syndrome
Succinate dehydrogenase mutations
Neurofibromatosis
Tuberose sclerosis

64

MEN II

Autosomal dominant
Activating mutation in tyrosine kinase receptor (RET proto-oncogene)
Associations:
Medullary thyroid cancer
Parathyroid hyperplasia
Bilateral phaeochromocytomas

65

What is MENII associated with?

Medullary thyroid carcinoma
Bilateral phaeochromocytoma
Parathyroid carcinoma

66

Von Hippel Lindau Syndrome

Mutation in HIF 1-a
Autosomal dominant
Range of vascular tumours
Family screening vital

67

Succinate Dehydrogenase

SDH – B, C & D
Inactivating mutations – stabilise HIF-1a
50% extra-adrenal
SDH-D = head & neck PGL; > 70% penetrance
SDH-B = malignant PGL; < 50% penetrance

68

Pitfalls in Phaeochromocytoma

catecholamines raised in heart failure

episodic catecholamine secretion - levels in plasma + urine may be normal

malignant and extra-adrenal tumours less efficient at catecholamine synthesis  Dopamine > Norepinephrine >Adrenaline

remember genetic syndromes

69

Permanent agranulocytosis is a serious side effects of which drugs?

Agranulocytosis - big decrease in WBC, particularly neutrophils
Carbimazole and propylthiouracil (drugs for hyperthyroidism)

70

Someone presents insidiously with diastolic hypertension...

Phaeochromocytoma

71

What is a dermoid cyst?

Contains mature material like skin, hair follicles and sweat glands
(i.e. material usually found on the outside)
-usually present in teenage years

72

Cystic hygroma

Posterior triangle swelling
Contains lots of watery fluid
ALMOST ALWAYS FOUND IN CHILDREN
-present from birth
-often large and disfiguring
-just below angle of mandible
-lymph fluid
-transilluminate

73

congenital epithelial cysts, which arise on the lateral part of the neck from a failure of obliteration of the second branchial cleft in embryonic development

Branchial cysts

74

Level of carotid bifurcation?

Level of the superior border of the thyroid cartilage
(vertebral body C4)

75

What does a branchial cyst contain on fine needle aspiration?

Cholesterol crystals

76

"half filled hot water bottle"

Branchial cyst

77

Branchial cyst and cystic hygroma, anterior or posterior swellings?

Branchial cyst : anterior triangle
Cystic hygroma: posterior swelling

78

FNA thyroid and when you should re do aspiration?

inadequate Thy 1- repeat FNA
benign Thy 2 – repeat FNA 6/12
suspicious Thy 3 – thyroid lobectomy
malignant Thy 4-5 – total thyroidectomy

79

How is ADH assessed?

Urine osmolarity

80

Low sodium but volume stats unremarkable, what should you think about?

SIADH
-diagnosis of water excess as the cause is often done as diagnosis of exclusion

81

Talk to me about hypovolemia

Hypovolaemia implies water deficit. If it is present when [Na] is low, then there must be an even bigger sodium deficit. This is important:
hypovolaemia in hyponatraemia → too little sodium.

Hypervolaemia is most often seen as oedema. This too is useful as it gives useful information about sodium and water balanc

82

What does hypovolemia in hyponatremia mean?

Too little sodium

83

What is derived from Rathke's pouch?

Anterior pituitary

84

Acidophils

Somatotrophs
Mammotrophs
(GH and PRL)
anterior pituitary

85

Basophils

Corticotrophs
Thyrotrophys
Gonadotrophs

86

Location of mineralocorticoid receptors?

Kidneys
Salivary glands
Gut
Sweat glands

-sodium/potassium balance
-blood pressure regulation
-control of extracellular volume

87

Loosers zones

Osteomalacia

88

Adrenal crisis

Extreme fatigue
V v. low serum sodium, high serum K
Dehydration
Vascular collapse (because of low BP)
Renal shut down

89

Which autoimmune diseases are associated with Addisons?

T1Dm
Pernicious anemia
Autoimmune thyroid disorders

90

Normal results of short SynACTHen test?

Normal: cortisol = baseline >250nmol/L, post : >480

91

Hydrocortisone as cortisol replacement

If unwell, give intravenously first
Usually 15-30mg daily in divided doses
Try to mimic diurnal rhythm

92

Which kind of tumour will take up MIBG?

Phaechromocytoma

93

What might someone with a phaeochromocytoma die from?

Arrhythmia
Ischemia

94

Carcinoid syndrome

Abdominal pain that comes and goes
Bright red flushing of the face, neck, or upper chest
Diarrhea
Heart palpitations
Low blood pressure
Skin lesions on the face called telangiectasias
Wheezing

95

Advice you should give patients if they are taking long term steroids?

-Know how to increase steroid replacement dose for intercurrent illness
-Carry a 'steroid' card
-Wear a Medic-Alert bracelet (gives details of their condition so tat emergency replacement therapy can be given if found unconscious)

96

Hirsutism developing before puberty is suggestive of what?

CAH

97

Biochemistry classical of Addisons?

Classically hyponatremia, hyperkalaemia, high urea (although biochem may be normal)

98

Severe hypotension and dehydration precipitated by intercurrent illness, accident or operation?

ADDISONIAN CRISIS

99

Most common cause of ambiguous genitalia?

CAH