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Adrenal/steroids Flashcards

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1
Q

When does physiological cortisol peak?

A

6-9am

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2
Q

Which factors have a positive feedback on cortisol production?

A

stress, Adr/NA, ghrelin

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3
Q

Which drugs have a negative feedback on cortisol production?

A

opioids

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4
Q

Which autoantibodies exist in >90% of addison’s patients?

A

21-hydroxylase

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5
Q

Which complications of addison’s disease should you be wary of?

A

Other autoimmune conditions, e.g. vitligo, coeliac disease, adrenal crisis

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6
Q

What are triggers for adrenal crisis?

A

acute stress, infection, haemorrhage

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7
Q

How to clinically distinguish primary adrenal insufficiency from secondary and tertiary? (signs)

A

no hyperpigmentation and no dehydration in 2+3

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8
Q

What would be the initial management plan for someone with suspected hypoadrenalism?

A

IV fluids, IV hydrocortisone, DVT prophylaxis, antiemetic

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9
Q

What are the causes of hypoadrenalism?

A
  1. Infections (TB, meningococcal)
  2. Drugs
  3. Metastatic destruction of adrenal glands
  4. Congenital adrenal hyperplasia
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10
Q

What is the protocol for short synacthen test?

A
  1. Ensure no glucocorticoid therapy given that morning
  2. Early morning ACTH and cortisol levels taken
  3. Dose of synthetic ACTH 250 micrograms
  4. Blood taken 30 min post ACTH
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11
Q

Which condition that arises in pregnancy can result in adrenal insufficiency?

A

Sheehan syndrome. life-threatening amount of blood in childbirth or who have severe low blood pressure during or after childbirth, which can deprive the body of oxygen. This lack of oxygen that causes damage to the pituitary gland

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12
Q

Which drug prescription can induce adrenal insufficiency?

A

steroids

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13
Q

In secondary and tertiary adrenal insufficiency, are mineralcorticoids still produced?

A

yes

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14
Q

Which is the most common cause of adrenal insufficiency in children?

A

congenital adrenal hyperplasia

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15
Q

What happens to the levels of Na and K in adrenal insuffiency?

A

Decreased Na and incr K

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16
Q

Why does bronzing occur in primary adrenal insufficiency?

A

ACTH stimulates melanocytes

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17
Q

Name two symptoms of adrenal insuffiency

A

muscle cramps, N/V

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18
Q

What is the treatment for adrenal insufficiency?

A

hydrocortisone and fludrocortisone

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19
Q

Is fluodrocortisone necessary in secondary and tertiary adrenal insufficiency?

A

unnecessary

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20
Q

If a patient with addison’s disease is sick, how should this affect their routine medications?

A

double dosage of corticoseroids but maintain the fludrocortisone dose

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21
Q

Two catabolic effects of cushing’s syndrome

A

 Proximal myopathy
 Striae
 Bruising
 Osteoporosis

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22
Q

Two glucocorticoid effects of cushing’s

A

DM

obesity

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23
Q

Two mineralcorticoid effects of cushing’s?

A

HTN

hypokalaemia

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24
Q

Describe three features of the appearance of someone with cushing’s

A 
  Moon face 
  Acne and hirsutism 
  Interscapular and supraclavicular fat pads 
  Centripetal obesity 
  Striae 
  Thin limbs 
  Bruising 
  Thin skin
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25
How is cushing's syndrome categorised/divided?
ACTH independent | ACTH dependent
26
Two differentials for ACTH independent cushing's?
 Iatrogenic steroids: commonest cause  Adrenal adenoma / Ca: carcinoma often → virilisation  Adrenal nodular hyperplasia
27
Two differentials for ACTH dependent cushing's?
cushing's disease | ectopic-ACTH
28
An example of ectopic-ACTH cause?
SCLC | Carcinoid tumour
29
Two investigations for cushing's syndrome?
24hr urinary free cortisol Late night serum or salivary cortisol Dexamethasone suppression test ACTH
30
Which condition would show cortisol suppression in dexamethasone suppression test?
cushing's disease only
31
Explain the dexamethasone suppression test
low dose test- confirms cushing's syndrome high dose test -low cortisol= cushing's disease - high cortisol- high ACTH= ectopic ACTH, low ACTH= adrenal cushings, iatrogenic
32
What is cushing's disease?
pituitary adenoma producing excess ACTH
33
What is conn's syndrome?
adrenocorticol adenoma
34
Two causes of primary hyperaldosteronism?
bilateral adrenal hyperplasia | adrenocortical adenoma= conn' syndrome
35
Which biochemical abnormality is present in hyperaldosteronism?
hypokalaemia
36
Two causes of secondary hyperaldosteronism?
``` diuretics nephrotic syndrome hepatic failure CCF RAS abnormalities ```
37
Brief pathophysiology of hyperaldosteronism?
increases renin concentration due to reduced renal perfusion
38
How can you distinguish between primary and secondary hyperaldosteronism?
aldosterone: renin ratio Raised in primary Normal in secondary
39
Two symptoms of hyperaldosteornism?
HTN | weakness, hypotonia, cramps- hypokalaemia
40
What are the effects of aldosterone?
increases expression in Na/K ATPase and eNaC following steroid receptor activation which results in the transcription of these channels in the distal convoluted tubule (and collecting duct)
41
Patient has very high aldosterone but low renin. What might be the diagnosis?
primary aldosteronism
42
What is the most common cause of secondary hypertension?
primary aldosteronism
43
Which test is employed to test aldosterone levels/function?
saline suppression test, if aldosterone levels are still high then very suspiscous of primary aldosteronism as aldosterone levels should be reduced
44
Three causes of primary adrenal insufficiency?
 Autoimmune destruction: 80% in the UK  TB: commonest worldwide  Metastasis: lung, breast, kidneys  Congenital: CAH
45
Three symptoms of primary adrenal insufficiency?
 Wt. loss + anorexia  n/v, abdo pain, diarrhoea/constipation  Lethargy, depression  Hyperpigmentation: buccal mucosa, palmar creases  Postural hypotension → dizziness, faints  Hypoglycaemia  Vitiligo  Addisonian crisis
46
Two abnormal findings in blood tests of primary adrenal insufficiency
hypoglycaemia hyponatraemia, hyperkalaemia hypocalcaemia
47
Which autoantibody is present in primary adrenal?
21-hydroxylase
48
Which is the main diagnostic test for addison's?
short synACTHen test
49
Treatment for addison's?
hydrocortisone | fludrocortisone
50
Name two pieces of advice to offer adrenal insufficiency patient
don't stop steroids suddenly increase dosage of steroids during injury, illness wear a medic-alert bracelet/have emergency info on phone
51
Two causes of secondary adrenal insufficiency?
chronic steroid use Sheehan's Pituitary microadenoma
52
What is Sheehan's syndrome?
Excessive blood loss during or after delivery of a baby may affect the function of the pituitary gland, leading to a form of maternal hypopituitarism
53
How to distinguish between primary and secondary adrenal insufficiency?
Normal mineralcorticoid in secondary | No pigmentation in secondary
54
Two clinical features of addisonian crisis?
shock- tachy, oliguria, confused, postural drop | hypoglycaemia
55
State one hereditary association of phaechromocytomas?
MEN2a and 2b
56
Three seminal features of phaechromocytoma presentation?
episodic headache, sweating, tachycardia
57
Two investigations for phaechromytoma?
Abdo CT and plasma + urine metadrenaline
58
Prior to adrenlectomy for phaeochomocytoma, what must be given pre-op?
alpha blocker first, then beta blocker pre-op
59
Emergency presentation of phaechromocytoma?
hypertensive crisis
60
Three causes of hypopituitarism?
Tumour, inflammation, infection, ischaemia, trauma of hypothalamus, pituitary stalk, or pituitary gland
61
Two common causes of panhypopituitarism?
surgery tumour irradiation
62
Name three hormone deficiencies that arise in hypopituitarism?
GH LH/FSH TSH ACTH
63
Three causes of hyperprolactinaemia?
``` lactation pregnancy prolactinoma pituitary adenoma antiemetics: metoclopramide antipscyhotics: haloperidol (physiological, pituitary, pharmacological) ```
64
Three symptoms of hyperprolactinaemia?
 Amenorrhoea  Infertility  Galactorrhoea  ↓ libido
65
Patient is exhibiting symptoms of hyperprolactinaemia. The result of their basal prolactin test is 5907. What is the diagnosis?
prolactinoma >5000
66
Three investigations for hyperprolactinaemia?
Pregnancy test TFTs Serum prolactin MRI
67
What is the treatment for hyperprolactinaemia?
DA agonist- cabergoline or bromocriptine
68
What is the number one cause of acromegaly?
pituitary adenoma
69
Three symptoms of acromegaly?
```  Acroparaesthesia  Amenorrhoea, ↓libido  Headache  Snoring  Sweating  Arthralgia, back ache  Carpal tunnel (50%) ```
70
Four signs of acromegaly?
Hands- thenar wasting, increased skin fold thickness Face- goitre, widely spaced teeth, wide nose, big ears, prominent supraorbital ridges
71
Two complications of acromegaly?
``` Impaired glucose tolerance DM HTN Cardiomyopathy Increased risk of IHD and stroke ```
72
Why does hyperglycaemia arise in acromegaly?
GH fails to suppress glucose in acromegaly
73
Two blood results of acromegaly?
Incr IGF1, incr glucose, ca, and PO4
74
Two features of clinical presentation of PCOS
symptoms of anovulation- amenorrhoea, oligomenorrhoea, irregular cycles hyperandrogenism- hirsutism, acne, alopecia.
75
Which hormones are raised in PCOS?
testosterone and LH
76
Which endocrine disorder does PCOS increase the risk of?
type 2 diabetes
77
What are the three components of POS pathophysiology?
gonadotrophins, androgens, insulin resistance
78
Which androgens are raised in PCOS?
testosterone, androstenedione, DHEAs
79
What is the major source of androstenedione in women?
ovary
80
What about DHEA-S?
adrenal gland
81
Which hormone will be able to tell you whether the abnormal androgen production is in the ovary or adrenal?
DHEA-S as 95% of this is produced by the adrenal, while testosterone androstenedione are produced in the adrenal gland AND ovary in equal-ish amounts
82
Testosterone is only biologically active when free. If there is increased production in PCOS, is there increased binding globulins?
reduced binding globulin, therefore more free androgens, leading to symptoms of PCOS
83
What is the main binding globulin for androgens?
SHBG
84
Which diabetes treatment can be used to treat PCOS?
metformin, improves insulin sensitivity and therefore leads to a decrease in LH levels, increases in SHBG, and decreased free androgens
85
What is the most effective treatment for PCOS symptoms?
calorie restriction
86
Which form of testosterone is biologically active?
free testosterone
87
Which enzyme converts testosterone to oestrogen?
aromatase
88
How does hypogonadism present in male child/young adult?
slow growth in teens, no growth spurt, small testes and phallus, lack of secondary development
89
How does hypogonadism present in adults?
depression/low mood, poor libido, erectile problems, poor muscle, sparse body hair, gynoid weight gain
90
What is gynoid weight gain?
weight around the chest, hips, and thighs
91
Once a history suggests hypogonadism, which tests should be done?
1. Testosterone- free, early, SHBG 2. FSH and LH. 3. Semen analysis
92
Why would you want to measure LH and FSH in hypogonadism?
to rule out pituitary involvement
93
In general, what are the two sources of causes for hypogonadism?
1. Hypothalamic-pituitary 2. Testicular problem
94
If you suspect hypogonadotrophic hypogonadism as there is low testosterone and low FSH+LH, which further tests should you do and why?
prolactin, cortisol, TSH...to ensure the whole pituitary is working
95
Three causes of hypogonadotrophic hypogonadism?
1. pituitary tumour 2. Genetic syndromes 3. Surgery 4. Head injury 5. Cerebellar ataxia 6. Kallmann's syndrome
96
15 y/o male with poor sense of smell, poor hearing, and impaired growth, what is the likely diagnosis?
Kallmann's syndrome
97
What would the levels of testosterone, LH/FSH, and prolactin be in primary gonadal disease?
low test, normal/high FSH/LH, normal prolactin
98
Three differentials for primary gonadal disease?
1 Kleinefelter's 2 trauma/chemo/radiotherapy can lead to seminiferous tubule and leydig cell failure 3 cryptorchodism
99
What is the most common genetic cause of male hypogonadism?
Klinefelter's syndrome
100
How does Klinefelter's present clinically?
wide clinical variation in phenotype due to hormonal respone to LH surges. In general, delayed puberty, suboptimal genital development, reduced secondary male sexual characteristics, behavioural difficulties
101
Two treatments for hypogonadism in males?
androgen replacement therapy, fertility treatment

Endocrinology (9 decks)

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