Adrenal disorders

Question 1

Name what they produce:
Zona Glomerulosa
Zona Fasiculata
Zona Reticularis

Answer 1

Zona Glomerulosa
- Aldosterone

Zona Fasiculata
- Cortisol

Zona Reticularis
- Androgens

Question 2

Using the Hypothlamaic pituitary adrenal axis, describe the production of cortisol, aldosterone, and adrenal androgens

Answer 2

1. Hypothalamus makes CRH + AVP
2. ACTH is made from the pituitary gland
3. Signals the adrenal glands to make cortisol, aldo, androgens

Question 3

RAAS

Answer 3

1. Adrenal gland makes aldosterone
2. Signals the kidney to make Renin
3. Renin converts Angiotensinogen (which is made in liver) to Angiotensin I
4. ACE (in lungs) converts Angiotensin I to Angiotensin II
5. AG II causes vasoconstriction (increase BP)

Question 4

Causes of Primary Adrenal insufficiency

1. Autoimmune:
2. Infectious:
3. Infiltrative
4. Other

Answer 4

1. Autoimmune:
   - Addison’s dz
2. Infectious:
   - TB, Fungi, HIV
3. Infiltrative:
   - Amyloid
4. Other
   - Hemorrhage
   - Metastatic
   - Metabolic
   - Surgery

*All will result in lower amts of cortisol, aldo, androgens

Question 5

Symptoms of Adrenal insufficiency

Answer 5

Non specific
- Fatigue, weakness, myalgias, arthralgias, anorexia, n/v, HA, abdominal pain, weight loss, postural dizziness, salt cravings

Question 6

Signs of Adrenal insufficiency

SIgns of primary adrenal insufficiency

Answer 6

ALL:
- Hypotension, Tachycardia

Primary:
- Vitiligo, pigmentation

Question 7

Labs of Adrenal insufficiency

Answer 7

1. HYPERkalemia (primary only)
2. HYPOnatremia
3. HYPOglycemia
4. Azotemia (high BUN + sr Creatinine)
5. Anemia
6. Eosinophilia

Question 8

How to dx Primary adrenal insufficiency

Answer 8

1. Serum cortisol
   100 pg/ml
2. Adrenal CT Scan
   Small: autoimmune, metabolic
   Large: all other causes

Question 9

Hashimoto’s thyroiditits (causing hypothyroidism) is it APS 1 or APS 2?

Answer 9

APS-2

HLA associated

Question 10

Best imaging for adrenal insufficiency

Answer 10

CT

Small: autoimmune, metabolic
Large: all other causes

Question 11

Secondary adrenal insufficiency is due to what?

Answer 11

1. Glucocorticoids
2. Opioids
3. Tumor
4. Surgery
5. Radiation
6. Infectious
7. Hemorrhage
8. Infiltrative
9. Metastatic

*Low CRF, Low ACTH –>
Low cortisol, NL aldosterone (no hyperkalemia), low adrenal androgens

Question 12

How to dx secondary adrenal insufficiency

Answer 12

Almost same as primary:

1. Serum cortisol

Question 13

Tx for adrenal insufficiency

Answer 13

Glucocorticoid replacement

• Hydrocortisone
• Prednisone
• Dexamethasone

Mineralocorticoid Replacement
- Fludrocortisone

Question 14

Triad of Primary aldosteronism

Answer 14

1. HTN
2. Hypokalemia
3. Metabolic alkalosis

Question 15

Two types of primary aldosteronism

Answer 15

1. Aldosterone producing adenoma (APA)
   34%
2. Idiopathic Hyperaldosteronism (IHA)
   66%

Question 16

Who to screen for primary aldosteronism?

Answer 16

Hypertensive patients with:

1. Hypokalemia
2. Severe HTN (>160/100)
3. Resistant HTN
4. HTN onset

Question 17

Positive screen for primary aldosteronism

Confirming test

Answer 17

Positive screen:
1. Morning plasma aldosterone (PA)
>15 ng/dl AND
2. PA/Plasma renin activity (PRA) ratio
>20

Confirmation test:

1. Oral salt load > 12 ug on urine aldosterone on 3rd day
2. IV saline infusion(2L NS over 4 hrs)

Question 18

Medication restriction for primary aldosteronism

Answer 18

Spirinolactone

- aldosterone antagonist

Question 19

What is a surgical disease? What is medical management only?

APA vs IHA?

Answer 19

APA: surgical management is option

• start with abdominal CT scan
• If cant visualize, do adrenal vein sampling

IHA: medical management only

Question 20

Direct aldosterone antagonist on kidney

Answer 20

Spirinolactone

Eplerenone

Question 21

Tx for primary aldosteronism (APA)

Answer 21

preop:
Aldosterone antagonist (spirin, epleren)

Adrenalectomy:
Laparoscopic/open

Question 22

Tx for primary aldosteronism (IHA)

Answer 22

preop:
Aldosterone antagonist (spirin, epleren)

BP medication:
CCB
ACE I
ARB

Question 23

Pheochromocytoma triad (4)..

Answer 23

HTN +
HA +
Sweating +
Palpitation

Due to excess catecholamine production

Question 24

Rule of 10s for pheochromocytoma

Answer 24

10% are malignant
10% are familial
10%are bilateral
10% are extra adrenal

Question 25

Familial syndromes that can lead to pheochromocytoma

Answer 25

1. MEN type 2A/2B 2. Von Hippel Lindau Syndrome 3. Neurofibromattosis Type I 4. Familial paragangliomas (Succinyl dehydrogenase SDH mutation)

Question 26

Who to screen for pheochromocytoma

Answer 26

Hypertensive patients with: 1. SPells - HA, sweating, palpitations 2. Severe HTN (>160/100) 3. Resistant HTN (>2 drugs) 4. Adrenal incidentaloma 5. Familial syndrome

Question 27

Best screening test for pheochromocytoma

Answer 27

Urine metanephrines and catecholamines sensitivity 90% specificity 98%

Question 28

What can cause false positives for pheochromocytoma (cause elevated catecholamines)

Answer 28

1. Levodopa 2. Ethanol 3. TCA 4. Buspirone (antipsychs) 5. Acetaminophen 6. Amphetamines, Opioids 7. Clonidine withdrawl 8. Renal failure 9. Sleep apnea 10. Physical stress

Question 29

Preop management for pheochromocytoma prior to adrenalectomy

Answer 29

Hypertensive, but hypovolemic (cant suddenly vasodilate them) 1. Alpha blockers (1st) - block norepi (Phenoxybenzamine, prazosin, terazosin, Doxazosin) 2. Beta blockers (2nd after alpha blockade) 3. CCB (alone) Tx effects: - volume expansion, vasodilation, rate control

Question 30

Cushing syndrome is due to what?

Answer 30

Exogenous steroids - most common cause The rest are adenoma-like: 80% are due to ACTH secreting pituitary tumor (cushing disease) - increase cortisol, NL aldosterone, increase adrenal androgens - ACTH dependent cushing syndrome 10% is due to cortisol secreting adrenal tumor (not ACTH secreting) - ACTH independent cushing syndrome

Question 31

Symptomes of cushing syndrome Signs

Answer 31

Santa Claus: 1. facial plethora 2. easy bruising 3. Fatigue, weakness, HA, weight gain Signs: 1. HTN 2. Central obesity 3. Purple stretch marks 4. Muscle weakness 5. Thin skin 6. Hirsutism "cushingoid" Cataracts, Ulcers, Skin: (striae, thinning, bruising), Hypertension/ hirsutism/ hyperglycemia, Infections, Necrosis, Glycosuria, Osteoporosis, obesity, Immunosuppression, and Diabetes

Question 32

Lab findings for cushing syndrome

Answer 32

Hyperglycemia Hyperlipidemia * commonly caused by corticosteroids/excess cortisol - need more E, gluconeogenesis, break down lipids - find in blood

Question 33

Adrenal incidentaloma

Answer 33

Frequent finding on abdominal imaging - usually benign - usually non functioning

Question 34

Benign vs malignant adrenal incidentaloma

Answer 34

benign - High lipid CT scan (low HU) - Low uptake FDG PET Malignant tumor - Low lipid (high HU) - High uptake FDG uptake

Question 35

Surgical Management of adrenal incidentaloma if...?

Answer 35

Surgical removal: 1. size >4.5 cm 2. Progressive growth 3. Hormone secretion *note: malignant adrenal tumors are ~ 6cm