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Flashcards in adrenal disorders Deck (53):

Causes of primary adrenal insufficiency

1. Autoimmune destruction of adrenal gland: Addison’s Dz. 2. Infectious: TB, Fungi, HIV. 3. Infiltrative: Amyloid. 4. Hemorrhage. 5. Metastatic. 6. Metabolic*. 7. Surgery


causes of secondary adrenal insufficiency

Exogenous glucocorticoid withdrawal (common), cure of Cushings syndrome (less common), opioids, radiation, infectious, hypothalamic/pituitary lesions (uncommon)


Hormone levels in primary vs secondary adrenal insufficiency

primary: Cortisol, aldosterone and adrenal androgens are low, but ACTH and CRF are high. Secondary: cortisol, adrenal androgens, ACTH and CRF are all low, and aldosterone is nl


Signs/symptoms of adrenal insufficiency

Chronic: fatigue, weakness, myalgias, arthralgias, nausea, weight loss, salt craving, hypotension, tachycardia. Acute: above plus fever, hypotension, confusion


labs of adrenal insufficiency

hyponatremia, hypoglycemia, azotemia, anemia (hemodilution), eosinophilia (cortisol lowers eosinophils)


What are signs/sx/labs that show up in primary adrenal insufficiency only

Vitiligo, pigmentation, hyperkalemia


What causes hyponatremia in AI

Decreased cortisol causes decreased cardiac output and decreased vascular tone. This creates a relative hypovolemia which causes stimulation of ADH, increased free water reabsorption and hyponatremia


What causes hyperkalemia in primary AI

The adrenal cortex is damaged, so patients lack aldosterone which leads to decreased sodium reabsorption and decreased potassium excretion by the kidney.


What causes hyperpigmentation in primary AI

Increased production of POMC (an ACTH precursor in the pituitary). POMC is also used as a precursor for melanocyte stimulating hormone so elevated levels lead to hyperpigmentation. In secondary AI, this does not occur b/c ACTH levels and POMC levels are low.


What is polyglandular autoimmune syndrome (type 2)

Clustering of autoimmune adrenal insufficiency with the following: hypothyroid, and type 1 diabetes. HLA asssociated


What is polyglandular autoimmune syndrome (type 1)

Autoimmune insufficiency plus hypoparathyroidism, type 1 diabetes and mucocutaneous candidiasis. Associated with an autoimmune regulator gene


Proposed mechanism of polyglandular autoimmune syndrome (type 2)

1. endocrine cell undergoes non-specific cellular damage (viral, toxin). 2. non-susceptible individual does not recognize the autoantigen or develops tolerance and the gland recovers. 3. a susceptible individual recognizes autoantigen as foreign leading to immune attack on the gland, with subsequent hypofunction


Best imaging tool for adrenal glands



Compare normal vs abnormal adrenal glands on imaging

normal body size is 5-8mm, limb size is 2-3mm and total width is 2-3cm. Abnormal gland may be small atrophic +/- calcifications (autoimmune or metabolic) OR enlarged with hemorrhage or necrosis (infctious, hemorrhage or mets)


risk facors for adrenal insufficiency

other autoimmune diseases, coagulopathy/sepsis /trauma (adrenal hemorrhage), HIV/AIDS, known malignancy, recent glucocorticoid treatment/ withdrawal, recent complicated delivery (pituitary infarct), or head trauma (pituitary infarct).


Primary adrenal insufficiency diagnosis

1. serum cortisol: 100pg/ml. 3. Adrenal CT scan: small adrenal gland if autoimmune or metabolic. Large if other causes


caveat to cosyntropin testing

If pituitary/hypothalamus injury is recent (2 weeks to 6 months), the adrenal gland may still respond to cosyntropin stimulation


Stages of primary adrenal insufficiency

stage 1: increased plasma renin activity and decreased or nl plasma aldosterone. Stage 2: stage 1 plus decreased cortisol response to ACTH. Stage 3: stage 2 plus increased plasma ACTH. Stage 4: clinically overt AI


Diagnosis of secondary adrenal insufficiency

1. serum cortisol: <20ug/dl after 10-60 minutes following cosyntropin (synthetic ACTH). 2. Plasma ACTH nl or low. 3. Pituitary MRI shows pathology


Adrenal insufficiency treatment

Primary only: mineralocorticoid replacement with Fludrocortisone. Primary + Secondary: glucocorticoid replacement with hydrocortisone, prednisone and/or dexamethasone


Sx of primary aldosteronism

hypertension, hypokalemia and metabolic alkalosis due to elevated aldosterone secretion


prevalence of primary aldosteronism in hypertensive pts



Levels of renin and angiotensin II in primary aldosteronism

Both are low due to negative feedback by aldosterone


Types of primary aldosteronism

1. aldosterone producing adenoma (34%). 2. idiopathic hyperaldosteronism aka bilateral adrenal hyperplasia (66%). 3. glucocorticoid-remediable hyperaldosteronism (rare). 4. aldosterone producing carcinoma (rare)


What causes glucocorticoid-remediable hyperaldosteronism

a mutation which fuses the promoter of 11-B hydroxylase (involved in cortisol synthesis) with aldosterone synthase creating a hybrid glomerulosa/fasciculata layer which produces aldosterone under the positive control of ACTH. Autosomal dominant. glucocorticoid treatment will inhibit ACTH, thus decreasing aldosterone release


Who should be screened for primary aldosteronism

hypertensive pts with hypokalemia (spontaneous or provoked by diuretics), severe HTN (>160/100), resistant HTN (>2 drugs), HTN earlier than 40 yrs, adrenal incidental adenoma, first degree relative with primary hyperaldosteronism


Diagnosis of primary aldosteronism

Morning samples: Plasma aldosterone >15ng/dl AND Plasma aldosterone/ plasma renin activity ratio >20. Restrict spironolacton usage. Plasma renin activity = direct renin/8


Primary aldosteronism confirmation tests

Sodium suppression testing: 1. Oral salt load -high NaCl diet for 3 days followed by a 24 hr urine aldosterone >12ug confirms diagnosis. 2. IV saline infusion- 2L NS over 4 hrs followed by plasma aldosterone >10ng/dl confirms diagnosis


How do you determine whether primary aldosteronism is due to adenoma or hyperplasia

adenoma is likely if age >40, severe HTN, hypokalemia, plasma aldosterone > 25ng/dl, urine aldosterone >30ug/24hrs. 1. CT abdomen. 2. adrenal vein sampling: lateralization indicates adenoma, no lateralization indicates hyperplasia.


Imaging of adrenal hyperplasia and adenomas

Anatomic: CT is best, MRI. Functional: PET, adrenocortical scintigraphy. Interventional: adrenal venous sampling


compare imaging of adrenal hyperplasia vs adenoma

Hyperplasia: enlarged limbs of one or both glands, normal shape, can be multinodular. Adenoma: round/oval mass, CT shows homogenous low density


What is adrenocortical scintigraphy

NP-59 is a cholesterol analog which binds to adrenal LDL receptors.


Treatment of primary aldosteronism

If aldosterone producing adenoma: pre-operative aldosterone antagonists then unilateral adrenalectomy. If idiopathic hyperaldosteronism: medical management with spironolactone or eplerenone plus BP meds (Ca channel blocker, ACEI, ARB)


What is a pheochromocytoma

tumor of the chromaffin cells in the adrenal medulla leading to excess NE and epi. Can also arise from extra-adrenal chromaffin tissue anywhere along the sympathetic chain in which case they are referred to as paragangliomas.


Pheochromocytoma Sx

HTN, headaches, sweating, palpitations


pheochromocytoma rul of 10s

10% are Malignant, 10% are Familial, 10% are Bilateral, 10% are Extra-Adrenal


List familial syndromes associated with pheochromocytoma

MEN type 2A/2B (mutation of ret receptor causes constitutive activation of neuroendocrine cells), von Hipppel Lindau syndrome, Neurofibromatosis type 1, familial paragangliomas (SDH mutations)


Who to screen for pheochromocytoma

hypertensive pts with spells of headaches, sweating and/or palpitations, severe HTN (>160/100), resistant HTN (>2 drugs), adrenal incidental adenoma, familial syndrome


Pheochromocytoma screening tests

1. urine metanephrines. 2. Urine catecholamines. 3. Plasma metanephrines. Urine tests are best screening tests but plasma metanephrines is best for high risk patients


Pheochromocytoma false positives

levodopa, ethanol, TCA, anti-psychotics, acetaminophen, amphetamines, renal failure, sleep apnea, physical stress


Endocrine principle of pheochromocytomas

a biochemical diagnosis must be established prior to the anatomic localization. This is especially true for many adrenal disorders since 5-10% of people will have an adrenal mass on CT scan, and a majority of these masses are non-functioning.


Pheochromocytoma localization tests

Abd MRI (hyperintense on T2, heterogenous) or CT, PET scans, MIBG (localization for ectopic, recurrent and metastatic tumors). Not hard to find.


Pheochromocytoma treatment

Preoperative: First alpha blockers (phenoxybenzamine, prazosin, terazosin, doxazosin), then beta blockers, OR calcium channel blockers alone. Adrenalectomy


Causes of Cushings Syndrome

1. 80% are endogenous- ACTH secreting pituitary tumor causes elevated cortisol and adrenal androgens. 2. 10% are ectopic ACTH secreting tumors causing elevated cortisol and adrenal androgens. 3. 10% are cortisol secreting adrenal tumors resulting in decreased ACTH, elevated cortisol and nl adrenal androgens


Cushings Syndrome clinical features

Fatigue, weakness, weight gain, facial plethora, easy bruising, HTN, central obesity, purple stretch marks, muscle weakness, thin skin, hirsutism, hyperglycemia, hyperlipidemia


Cushings syndrome screening

1. elevated 24 hr urine cortisol. 2. Elevated bedtime salivary cortisol. 3. Following 1mg dexamethasone suppression test, cortisol is >1.8ug/dl


Compare the results of a dexamethasone suppression test for the three different causes of Cushings syndrome

1. If pituitary ACTH secreting tumor, DST results in suppression of ACTH and cortisol. 2. If ectopic ACTH secretic tumor, DST does not suppress ACTH/ cortisol. 3. If adrenal cortisol secreting tumor, DST does not suppress ACTH/cortisol


Name conditions with hypercortisolism that is not Cushings

Pregnancy, depression, alcoholism, morbid obesity, diabetes (poorly controlled)


Cushings syndrome localization

Pituitary MRI, chest CT, Abdominal CT, inferior petrosal sinus sampling


Cushings syndrome treatment

1. surgery. 2. ACTH secretion inhibitors- Cabergoline, pasireotide. 3. Cortisol synthesis inhibitors- ketoconazole, metyrapone, etomidate. 4. adrenolytic agents- mitotane. 5. cortisol receptor blockers- mefispristone


What is an adrenal incidentaloma

Benign finding on abd imaging. Usually non functioning- most common hormone abnormality is cortisol secretion


Adrenal incidentaloma imaging

1. CT: if high lipid content/low HU it is benign. If low lipid content/high HU it is malignant. 2. PET: measure FDG uptake. If high it is malignant, if low it is benign


Adrenal incidentaloma surgery

remove if >4.5cm, progressive growth or hormone secretion.