The K regulation of aldo secretion only work if.....
if there are no interfering factors that limit aldosterone secretion or potassium excretion.
actions of adrenal androgens in males?
(Minimal role) Most testosterone produced in testes Excess causes suppression of gonadal function
Actions of adrenal androgens in femals?
Development of pubic and axillary hair Libido Excess causes suppression of gonadal function
disorders of hyperfunction of the adrenal cortex?
Cushing’s Syndrome (increased cortisol) Primary Aldosteronism (increased aldosterone) Adrenogenital Syndromes (increased androgens)
disorders of hypofunction of the adrenal cortex?
Primary Adrenocortical Insufficiency(Addison’s Disease) Secondary Adrenocortical Insufficiency
5 manisfestations of cushings syndrome based on hx?
Osteoporosis – early onset Poor wound healing Insomnia and psych disorders Polyuria and polydipsia (glycosuria) Amenorrhea, oligomenorrhea
9 manifestations on PE of cushings syndrome?
- Truncal obesity, “buffalo hump” - Plethora, moon-like” face - Easy bruising (ecchymoses), thin skin - Proximal myopathy (muscular weakness) - Broad red or purple striae (>1 cm wide) - Acne, hirsutism (virilizing signs) - Moderate HTN - Edema of lower extremities - Hyperpigmentation (with ACTH increase)
5 laboratory findings on pts with cushings?
Leukocytosis due to neutrophilia (No left shift (i.e. no increase in bands) Lymphopenia Hypokalemia Metabolic alkalosis Glucose intolerance (Overt diabetes in less then 20 percent of patients)
In pituitary cushing's syndrome, a pituitary adenoma willl....
Produce ACTH and it will go to both adrenal glands and stimulate coritcol from both adrenals and stimulate GROWTH causing adrenal hyperplasia b/l ** ACTH dependent
in Paraneoplasic cushing syndrome, the ACTH production from a non-endocrine tumor willl....
cause an increase in cortisol and b/l adrenal hyperplasia ** ACTH dependent
what are the 2 causes of ACTH independent causes of cushings syndrome?
adrenal tumor, adrenal hyperplasia, and iatrogenic cushing syndrome
iatrogenic cushing syndrome causes what changes to the gland?
adrenal gland atrophy
3 ways to establish the dx of endogenous cushing's syndrome?
- Exclude exogenous source of glucocorticoid - Demonstrate increased cortisol production - Demonstrate failure to suppress cortisol production(i.e., demonstrate autonomy of hypercortisolism)
What are the 4 tests used to exclude exogenous glucocorticoids?
Oral (Rx, herbals) Inhaled (lungs, nose) Topical (skin, rectal) Intraarticular
What are the 3 tests used to demonstrate increased coritsol production?
24-h urinary free cortisol (greater then 2 tests) Late night salivary cortisol (2 tests) (Midnight plasma cortisol)
what test is used to deomnstrate failure of cortisol to suppress?
Dexamethasone suppression tests ( 1 mg overnight 4 mg over 48h (std. dose DST)
what are 6 causes of false positive screening tests for cushings syndrome?
Depression, anxiety, OCD Severe obesity Poorly-controlled DM Chronic alcoholism Anorexia nervosa Acute illness **Multiple screening tests and clinical assessment are needed to rule out pseudo-Cushing’s syndrome.
What is 1 lab test and 3 imaging tests to dx the cause of cushings syndrome?
1. plasma ACTH 1. MRI of pit. 2. CT of adrenals 3.sampling of sinus for ACTH
The inferior petrosal sinus connects ____ to ____
cavernous sinus to the jugular vein
What is the cause primary adrenal insufficiency?
What is the seconadry cause of primary adrenal insufficiency?
- Exogenous therapeutic corticosteroids - hypopituitarism
Exogenous corticosteroids cause both
Cushing’s syndrome and adrenal insufficiency simultaneously.
Primary adrenal insufficiency usually involves who.... and usually requires _____
it is rare, and equal between men and women requires greater then 90 percent of gland being destroyed
What is the clinical manifestation of primary adrenal insufficiency?
- fatigue/weakness - Anorexia, N/V, weight loss - orthostatic HTN - hyperpigmentation - in females there is decreased axillary and pibic hair ** insidious and progressive
What are the lab findings in a pt with primary and adrenal insufficiency?
Early---(basal corticosteroid levels normal, but reserve is decreased; cannot respond to stress) Provocative test --- ACTH stimulation test: Cosyntropin (Cortrosyn; ACTH analog) I.M. or I.V....... Response will be subnormal. Late---hyponatremia, low bicarbonate (acidosis), hyperkalemia, hypoglycemia
What is the clinical presentation of an acute adrenal insufficiency "adrenal crisis"
Nausea, vomiting Abdominal pain with or without fever; muscle and joint aches Hypovolemic vascular collapse Hyperkalemia ---- arrhythmias Somnolence--- coma
treatment of acute adrenal insufficiency "adrenal crisis"
High dose I.V. hydrocortisone Aggressive fluid replacement and electrolyte management
what are 3 causes of primary aldosteronism
- Aldosterone-producing adrenal adenoma (Conn’s syndrome) - Bilateral adrenal hyperplasia -Adrenal carcinoma (rare)
What is a cause of secondary aldosteronism?
Increased aldosterone due to activation of the renin-angiotensin system
Age group that primary aldosteronism is common in?
2F:1M; age 30-50
clinical presentation of primary aldosteronism
Hypertension (systolic and diastolic)-- Headache, Left ventricular hypertrophy Hypokalemic symptoms and signs, if present (Muscle weakness, fatigue, Arrhythmias, Polyuria (decreased urinary concentrating ability) No edema (“aldosterone escape”)
Primary aldosteronism lab findings?
Low plasma renin with failure to rise on standing or with sodium depletion Non-suppressible elevation of plasma aldosterone Inconsistent findings-- (Hypokalemia Metabolic alkalosis (increased HCO3-) Hypernatremia
3 causes of secondary aldosteronism?
Hypertensive states (renal arery stenosis, malignant HTN, renin-producing renal tumor) Hypovolemic states Edematous states (CHF, cirrhosis, nephrotic syndrome)
7 sx associated with Virilazation in females?
1. beard 2. male pubic hair pattern 3. male pattern baldness 4. deep voice 5. amenorrhea 6. male muscular development 7. clitoral enlargment
2 sx associted with virilaztion in males?
increased libido and precocious puberty
2 sx associted in both sexes with loss of mineralocorticoid effects
Salt-wasting (hypotension and hyponatremia) Hyperkalemia
What is virilization
an increase in the androgen amount being released
What is a pheochromocytoma?
a tumor that is secreting both epi and dopamine
what are the clinical features of pheochromocytoma?
- Hypertension- (Resistant, Sustained (60 percent) or paroxysmal (40 percent), Orthostatic hypotension (decreaed plasma volume) Headache, sweating, tachycardia, palpitations, apprehension, pallor---esp. during paroxysmal attacks
What are the lab findings of a pt with pheochromocytoma?
Impaired glucose tolerance (mild) Increased hematocrit ( decreased plasma volume)
how to dx pheochromocytoma?
- 24-h urine for fractionated catecholamines and metanephrines - Plasma fractionated metanephrines **Beware of interfering drugs!