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M&M Test 3 > B6-100 CBCL Adrenal Incidentaloma > Flashcards

B6-100 CBCL Adrenal Incidentaloma Flashcards

1
Q

most superficial layer of the adrenal cortex

A

zona glomerulosa

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2
Q

middle layer of the adrenal cortex

A

zona fasciculata

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3
Q

deepest layer of the adrenal cortex

A

zona reticularis

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4
Q

medulla is made up of […] tissue

A

neural

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5
Q

the adrenal cortex is made up of […] tissue

A

glandular cuboidal epithelial tissue

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6
Q

low blood pressure cause the JG cells in the kidneys produce

A

renin

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7
Q

renin converts […] to […]

A

angiotensinogen to angiotensin I

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8
Q

converts angiotensin I to angiotensin II

A

ACE

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9
Q

angiotensin II goes to the zona glomerulosa and binds to a […]

A

G coupled protein receptor

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10
Q

describe how G coupled protein receptor activation leads to the activation of pkA

**may not be super relevant to this exam, but step review

A

angiontensin II binds to G-coupled protein receptor
stimulates adenylate cyclase
adenylate cyclase –> GTPase
GTPase converts GTP to GDP to produce ATP
ATP –> cAMP
cAMP activates protein kinase A

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11
Q

cells that are very sensitive to sodium and potassium changes reside in what part of the adrenal cortex?

A

zona glomerulosa

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12
Q

stimulate the zona glomerulosa to produce aldosterone [3]

A

low bp
hyponatremia
hyperkalemia

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13
Q

CRH is secreted from the

A

hypothalamus

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14
Q

CRH stimulates […] to secrete ACTH

A

corticotropes

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15
Q

ACTH binds to the adrenal cortex via […]

A

G coupled protein receptor

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16
Q

inhibits aldosterone synthesis (biologic substance, not a medication)

A

atrial natriuretic peptide

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17
Q

causes hyperpolarization of the cell resulting in potassium efflux out of the cell
inhibits aldosterone synthesis

A

ANP

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18
Q

hormone synthesis requires […] as the basic unit

A

cholesterol

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19
Q

[cholesterol pathway]
cholesterol is converted to […]

A

pregnenolone

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20
Q

[cholesterol pathway]
pregnenolone can be converted to […] [2]

A

progesterone
17-hydroxypregnenolone

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21
Q

[cholesterol pathway]
progesterone can be converted to […] [2]

A

11-deoxycorticosterone
17-hydroxypregnenolone

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22
Q

converts progesterone to 11-deoxycorticosterone

A

21-hydroxylase

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23
Q

[cholesterol pathway]
11-deoxycorticosone is converted to

A

corticosone

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24
Q

[cholesterol pathway]
corticosone is converted to

A

aldosterone

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25
Q

transportation proteins of cortisol [2]

A

CBG (aka transcortin)
albumin

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26
Q

aldosterone acts on what part of the nephron?

A

DCT

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27
Q

aldosterone binds to intracytosolic receptors to induce what changes?

A

upregulates:
NaKATPase in basolateral membrane
ENaC channels
K+ channels

overall effect: more sodium reabsorption –> more water reabsorption, more K+ excretion —-> increased blood pressure

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28
Q

what is the outer layer of the adrenal cortex?

A

zona glomerulosa

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29
Q

what is the middle layer of the adrenal cortex?

A

zona fasiculata

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30
Q

what tissue is the adrenal medulla made of?

A

neural tisse

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31
Q

what do JG cells produce?

A

renin

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32
Q

where does ACE come from?

A

lungs

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33
Q

what are the effects of aldosterone? [4]

A

increase bp
increase blood volume
increase serum sodium serum

decrease serum K+

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34
Q

ANP inhibits what?

A

ACTH

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35
Q

the […] in the hypothalamus triggers the release of CRH

A

paraventricular nucleus

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36
Q

ACTH is a strong stimulus for […] synthesis

A

cortisol

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37
Q

effect of cortisol in muscle

A

activates transcription factors to increase proteases in cell

proteases stimulate protein catabolism, releasing amino acids in to the bloodstream to go to liver

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38
Q

effects of cortisol on adipose

A

induces lipolysis

trigylcerides broken down to fatty acids and glycerol

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39
Q

effects of cortisol on the liver

A

activates transcription factors to induce gluconeogenesis and glycogenolysis

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40
Q

where do the factors required for gluconeogenesis come from?

A

amino acids and lactic acid from muscle

glycerol and fatty acids from adipose

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41
Q

process where glucose is converted to glycogen

A

glycogenesis

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42
Q

cortisol directly stimulates […] in the liver [2]

A

glycogenesis
gluconeogenesis

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43
Q

cortisol indirectly stimulates […] in the liver

A

glycogenolysis

**increases the sensitivity of adrenergic receptors for norepinephrine

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44
Q

cortisol increases the sensitivity of adrenergic receptors for

A

norepinephrine

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45
Q

how does cortisol affect blood vessels?

A

increases the sensitivity of adrenergic receptors for norepinephrine (basically magnifies the effect of NE)

vasoconstriction
increase blood pressure

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46
Q

how does cortisol effect the immune system?

A

inhibits inflammatory response

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47
Q

stimuli of cortisol [2]

A

hypoglycemia
chronic stress

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48
Q

cortisol responds to hypoglycemia by [3]

A

directly stimulating gluconeogenesis and glycogenesis

indirectly stimulating glycogenolysis

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49
Q

long term chronic stress can causes a direct release of CRH, leading to

A

excessive production of ACTH —> cortisol

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50
Q

cortisol responds to chronic stress by [3]

A

vasoconstriction –> HTN
muscle catabolism
depresses immune system

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51
Q

increased cortisol in the blood exerts […] on the hypothalmus to decrease CRH

A

negative feedback

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52
Q

decreased cortisol triggers the hypothalamus to

A

PVN—> more CRH
pituitary —> more ACTH

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53
Q

[cholesterol pathway]
17-hydroxypregnenolone is converted to

A

androstenedione

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54
Q

androstenedione effect on the testes and ovaries [3]

A

increases libido
development of secondary sex characteristics
stimulates sebaceous glands

**minimal amounts get converted to estrogen and testosterone respectively

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55
Q

mineralcorticoids are secreted by

A

zona glomerulosa

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56
Q

glucocorticoids are secreted by

A

zona fasciculata

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57
Q

androgens are secreted by the

A

zona reticularis

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58
Q

catecholamines are secreted by the

A

medulla

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59
Q

how does the hypothalamus stimulate catecholamine release?

A

stimulates the SNS to send potential to the lateral gray cord at Th1 to L2 —> ventral ramus —> adrenal medulla

thoracolumbar outflow

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60
Q

describe the catecholamine pathway

A

tyrosine to L-DOPA
L-DOPA to dopamine
Dopamine to norepinephrine
norepinephrine to epinephrine

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61
Q

enzyme in the adrenal medulla that converts norepinephrine to epinephrine

A

PNMT

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62
Q

epinephrine binds to the liver via G coupled protein receptor to induce [2]

A

glycogenolysis
gluconeogenesis

results in hyperglycemia

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63
Q

catecholamine’s effect on the adipose tissue

A

binds to HSL to induce lipolysis

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64
Q

catecholamine effects on the heart

A

stimulate the expression of b1 receptors and cells of the SA and AV node to increase blood pressure by increasing contractility and constricting vessels

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65
Q

the effects of catecholamines on the respiratory system

A

dilates bronchioles

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66
Q

CRH stimulates corticotropes to release

A

ACTH

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67
Q

main mineralcorticoid secreted by zona glomerulosa

A

aldosterone

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68
Q

[…] inhibits the zona glomerulosa

A

ANP

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69
Q

stimuli for the zona glomerulosa to secrete aldosterone [4]

A

ACTH
angiotensin II
hyponatremia
hyperkalemia

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70
Q

main glucocorticoid secreted by the zona fasciculata

A

cortisol

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71
Q

the main androgens secreted by the zona reticularis [2]

A

dehydroepiandrostene (DHEA)
androstenedione

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72
Q

the […] is stimulated by the SNS through thoracolumbar output

A

adrenal medulla

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73
Q

main catecholamines secreted by the adrenal medulla

A

epinephrine
norepinephrine

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74
Q

general effects of catecholamines

A

increase blood pressure
increase glycogenolysis
increase gluconeogenesis
increase lipolysis

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75
Q

aldosterone stimulates [2]

A

Na+ reabsorption
K+ excretion

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76
Q

effects of cortisol [5]

A

suppresses immune system
stimulates protein catabolism in muscle
stimulates lipolysis
stimulates gluconeogenesis
increases b-1 adrenergic receptors

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77
Q

androgens act as precursors to [2]

A

estrogen and testosterone

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78
Q

increased levels of cortisol in the blood decrease the production of [2]

A

CRH
ACTH

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79
Q

low levels of cortisol in the blood stimulates [2]

A

PVN in hypothalamus to produce CRH
anterior pituitary to produce ACTH

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80
Q

CRH stimulates the

A

anterior pituitary

81
Q

ACTH stimulates what part of the adrenal gland? [2]

A

zona fasciculata
zona reticularis

82
Q

is aldosterone stimulated by ACTH?

A

no

83
Q

a defect in the adrenal cortex results in a deficiency of [3]

A

cortisol
aldosteron
DHEA

84
Q

a defect in the pituitary results in a deficiency of what hormones released from the adrenal gland? [2]

A

cortisol
DHEA

**not aldosterone

85
Q

JG cells of the kidney release […] in response to low circulating blood volume

A

renin

86
Q

produces angiotensinogen

A

liver

87
Q

angiotensinogen is converted to angiotensin I in the blood by […]

A

renin

88
Q

angiotensin I is converted to angiotensin II by […], which is produced in the […]

A

ACE
lungs

89
Q

angiotensin II binds to receptors on the zona glomerulosa to stimulate […] production

A

aldosterone

90
Q

addison’s is a […] renal insufficiency

A

primary

91
Q

adrenal cortex is diseased, and the pituitary/hypothalamus is healthy

A

primary adrenal insufficiency

**addisons

92
Q

addison’s disease results in the drop of […] hormones

A

all 3

cortisol
DHEA
aldosterone

93
Q

most common cause of Addison’s disease

A

autoimmune

94
Q

expected ATCH and cortisol levels in primary adrenal insufficiency

A

ACTH high
cortisol low

95
Q

adrenal cortex healthy
pituitary diseased

A

secondary adrenal insufficiency

96
Q

common causes of secondary adrenal insufficiency [2]

A

tumor/trauma
chronic steroid therapy

97
Q

how does chronic long term steroid therapy cause secondary adrenal insufficiency?

A

steroids suppress ACTH production –>
adrenal cortex atrophies, preventing cortisol secretion

so when steroid is d/c the pituitary increases ACTH but there is no response from the adrenal gland due to atrophy

98
Q

[cushing disease or syndrome]
caused by increased cortisol production from tumors or hyperplasia

A

cushing’s syndrome

99
Q

[cushing disease or syndrome]
increased ACTH from the pituitary hyperstimulates the adrenal cortex causing increased cortisol

A

cushing’s disease

100
Q

causes of cushings syndrome [2]

A

tumors
chronic steroid use

101
Q

causes of cushings disease [2]

A

pituitary adenoma
ectopic ACTH producing cancer

102
Q

common causes of ectopic ACTH secreting tumors

A

small cell lung cancer
renal cell carcinoma
pancreatic islet cells tumor

103
Q

what is the normal response to low dose dexamethasone suppression test?

A

1 mg dexamethasone should suppress ACTH production and cortisol level

104
Q

if you draw ACTH and it is increased this indicates a tumor where?

A

pituitary or ectopic ACTH secreting

105
Q

if you draw ACTH and it is decreased this indicates what pathology?

A

adrenal tumor

or exogenous steroid consumption

106
Q

how would a pituitary tumor respond to high dose (8mg) dexamethasone?

A

ACTH and cortisol would decrease

107
Q

how would an adrenal tumor respond to high dose (8mg) dexamethasone?

A

no response, cortisol will remain high

108
Q

treatment for pituitary adenoma

A

transsphenoidal resection

109
Q

treatment for adrenal adenoma [2]

A

ketoconazole
adrenalectomy

110
Q

the majority of adrenal adenomas are [functional/nonfuctional]

A

nonfunctional

**less than 10% are functional

111
Q

tuberculosis can have what effect on the adrenal system?

A

adrenal insufficiency

112
Q

clinical manifestions of adrenal insufficiency

A

skin hyperpigmentation
nausea/vomiting
weight loss
fatigue
orthostatic hypertension

113
Q

expected labs in primary adrenal insufficiency

A

low cortisol
elevated plasma ACTH
low aldosterone

114
Q

why does the adrenal medulla preferentially release epinephrine?

A

expresses PNMT which converts NE to Epi

115
Q

does Cushing’s disease increase CRH?

A

no

the pituitary adenoma secretes ACTH independent of CRH

116
Q

enzyme that converts cortisol to cortisone, inactivating it

A

11beta-hydroxysteroid dehydrogenase (11betaHSD)

117
Q

the right adrenal gland drains into the

A

inferior vena cava

118
Q

the left adrenal gland drains into the

A

left renal vein

119
Q

the three arteries that supply adrenal glands

A

superior suprarenal from phrenic
middle suprarenal from aorta
inferior suprarenal from renal arteries

120
Q

an individual with pheochromocytoma should be treated for […] with beta/alpha blockers prior to surgery

A

two weeks

121
Q

nonselective inhibitor of adrenal and gonadal steroids

A

ketoconazole

122
Q

medication used to treat hyperaldosteronism

A

spironolactone

123
Q

aldosterone receptor antagonist

A

spironolactone

124
Q

characterized by hypersecretion of aldosterone from the zona glomerulosa

A

Conn syndrome

125
Q

classic presentation of Conn syndrome

A

refractory HTN
hypokalemia
metabolic alkalosis

126
Q

signs of Addison’s disease

A

orthostatic hypotension
weight loss
skin hyperpigmentation
salt cravings
hyponatremia
hyperkalemia

127
Q

autoimmune process that destroys the adrenal cortex

A

addison disease (primary adrenal insufficiency)

128
Q

ACTH would be […] in Addison’s disease

A

elevated

129
Q

[…] triggers the release of catecholamines from the adrenal medulla

A

acetlycholine

130
Q

most common cause of congenital adrenal hyperplasia

A

21-hydroxylase deficiency

131
Q

virilized genital
hypotension
hyperkalemia
hyponatremia

A

congenital adrenal hyperplasia

132
Q

what laboratory results would be expected in 21- hydroxylase deficient congenital adrenal hyperplasia?

A

elevated 17-hydroxyprogesterone
hyperkalemia
hyponatremia

133
Q

tumor of the adrenal medulla that oversecrete catecholamines

A

pheochromocytoma

134
Q

best initial test for diagnosis of pheochromocytomas

A

24 urine measurement of metanephrines

135
Q

episodic hypertension
palpitations
headaches
perspiration

A

increased catecholamine secretion (pheochromocytoma)

136
Q

patients with pheochromocytoma should be give a-antagonists and b-blockers prior to surgery to prevent ….

A

unopposed a-adrenergic vasoconstriction causing
hypertensive crisis

137
Q

cushing syndrome is caused by abnormally elevated […]

A

cortisol

138
Q

cortisol is secreted from the zona […]

A

fasiculata

139
Q

symptoms of cushing’s syndrome

A

hypertension
truncal obesity with striae
skin thinning
AMS

140
Q

salt water wasting
ambiguous female genitalia in females

A

congenital adrenal hyperplasia

141
Q

[…] deficiency is most common in CAH

A

21-hydroxylase

142
Q

the adrenal medulla contain […] cells

A

chromaffin

143
Q

chromaffin cells secrete [3]

A

epinephrine
norepinephrine
enkephalin

144
Q

the majority of neuroblastomas in children are […]

A

sporadic

145
Q

neuroblastoma tumors require […] testing

A

N-MYC

146
Q

adrenal medullary tumor often presenting with HTN

A

pheochromocytoma

147
Q

screening for […] in pheochromocytoma patients is recommended

A

most common germline mutations

148
Q

eosinophilic laminated cytoplasmic inclusions indicated treatment with

A

spironolactone

149
Q

what are urine metanephrines?

A

metabolites of catecholamines

**useful for evaluation of pheochromocytomas

150
Q

what tests may be useful in the workup of pheochromocytomas?

A

metanephrines and normetanephrines
serum ACTH
urine cortisol
salivary cortisol
dexamethasone suppression

151
Q

most likely underlying cause for an asymptomatic small adrenal nodule found incidentally

A

non functioning adrenal cortical adenoma

152
Q

most common cause of cushing’s syndrome

A

exogenous glucocorticoids

153
Q

best first step in evaluation of cushing’s syndrome

A

medication history

154
Q

most common cause for malignant adrenal gland tumor?

A

metastatic tumors to the adrenal gland

155
Q

metabolites of catecholamines [2]

A

vaillylmandelic acid
homovanillic acid

156
Q

catecholamine secreting tumors [2]

A

pheochromocytomas
neuroblastoma

157
Q

patients with adrenal suppression should be given […] prior to surgery to prevent shock

A

hydrocortisone

158
Q

hypertension and hypokalemia are hallmark symptoms of

A

hyperaldosteronism

159
Q

gluacoma
osteoporosis
diabetes

are symptoms of

A

prolonged steroid use

160
Q

confirmatory test for hyperaldosteronism

A

24-urine collection of aldosterone

161
Q

initial medical treatment of hyperaldosteronism

A

spironolactone

162
Q

labile hypertension, diaphoresis, adrenal mass

A

pheochromocytoma

163
Q

confirmatory test for diagnosis of pheochromocytoma

A

plasma metanephrines and normetanephrine

164
Q

a minimum of […] tests are necessary to diagnose cushings

A

2

165
Q

first line imaging for ACTH dependent Cushings

A

MRI pituitary

166
Q

metanephrine and normetanephrine are derived from what amino acid?

A

tyrosine

167
Q

imaging that is sensitive and specific for pheochromocytoma

A

MRI abdomen

168
Q

screening tests for cushings [3]

A

24-urine cortisol
late night salivary cortisol
dexamethasone suppression

169
Q

findings of Cushing’s syndrome

A

Metabolic syndrome (HTN, hyperglycemia, hyperlipidemia)
Obesity
Osteoporosis
Neuropsychotic (depression, anxiety, irriability)
Facial plethora
Androgen excess (acne, hirsutism)
Cataracts
Immunosuppression
Ecchymoses
Skin changes (thinning, striae, hyperpigmentation)

MOON FACIES

170
Q

presents as hypertension with
XY: atypical genitalia, undescended testes
XX: lack of secondary sex characteristics

A

CAH - 17a-hydroxylase deficiency

171
Q

presents in infancy with severe hypertension
virilization in females

A

CAH - 11b-hydroxylase deficiency

172
Q

in CAH, if the deficient enzyme starts with 1 it causes

A

HTN

173
Q

in CAH, if the deficient enzyme ends with 1 it causes

A

virilization in females

174
Q

decreased androstenedione on labs indicates CAH with what deficiency?

A

17-a hydroxylase

175
Q

increased renin and 17-hydroxyprogesterone on labs indicates CAH with what deficiency?

A

21-hydroxlase

176
Q

decreased renin activity on labs indicates CAH with what deficiency?

A

11b-hydroxylase

177
Q

exogenous glucocorticoids can cause reactivation of

A

TB

178
Q

most common tumor of the adrenal medulla in children

A

neuroblastoma

179
Q

tumor originating from neural crest cells

A

neuroblastoma

180
Q

decreased plasma renin activity
elevated blood pressure

A

primary hyperaldosteronism

181
Q

most common cause of primary hyperaldosteronism

A

idiopathic

**adrenocorticol neoplasms (Conn syndrome) is second

182
Q

genetic associations with adrenal carcinomas

A

Li Fraumeni (p53 mutation)
Lynch syndrome
MEN1
FAP
NF1
Beckwith Wiederman
CAH

183
Q

benign tumors composed for mature fat and hematopoietic elements

A

adrenal myelolipoma

184
Q

caused by aldosterone secreting adenoma

A

Conn syndrome

185
Q

most common cause of hypercortisolism

A

exogenous steroids

186
Q

neoplastic causes of hypercortisolism [3]

A
  1. pituitary adenoma (cushings disease)
  2. ectopic ACTH
  3. adrenal tumor secreting cortisol
187
Q

elevated ACTH
no reaction to low dose dexamethasone suppression, but eventually responds to high dose by suppressing ACTH

A

pituitary adenoma

188
Q

elevated ACTH
no response to low or high dose dexamethasone

A

ectopic ACTH secreting tumor

189
Q

low ACTH
no response to low or high dose dexamethasone

A

adrenal tumor independently secreting cortisol

190
Q

most common cause of endogenous hypercortisolism

A

ACTH secreting pituitary adenomas

191
Q

5 Ps of pheochromocytoma

A

Pressure (episodic HTN)
Pain
Perspiration
Palpitations
Pallor

192
Q

headache
sweating
palpitations

A

pheochromocytoma

193
Q

alpha blockers [2] and beta blocker [1] Keim listed in her slides for pheochromocytoma presurgical treatment

A

a: phenoxybenzamine, prazosin
b: propranolol

194
Q

treatment for pituitary adenoma

A

transsphenoidal resection

195
Q

treatment for adrenal adenoma

A

laparoscopic resection

196
Q

medication used if treatment is not an option for adrenal Cushing’s

A

ketoconazole

197
Q

when a patient with adrenal insufficiency is sick, […] the current steroids for three days

A

double

198
Q

if a patient with adrenal insufficiency is having major surgery, what should be done?

A

change to IV steroids (hydrocortisone) during the time of critical illness

199
Q
A

M&M Test 3 (16 decks)

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