Chronic Adrenal

Question 1

Pheochromocytoma

Answer 1

Pheochromocytoma is a catecholamine-secreting tumor of chromaffin (pheochromocyte) cells. Ninety percent are found in the adrenal medulla; others arise intra-abdominally along the sympathetic ganglion chain.

Question 2

ACTH Secretion Pattern

Answer 2

Normal circadian ACTH secretion is highest on waking and lowest at night. Men average 18 pulses of ACTH daily, but women have only 10.
Disrupted sleep-wake cycles of shift workers or travelers crossing time zones interrupt the pulses, which may result in changes in performance and behavior

Question 3

Addison Disease

Answer 3

Hypoadrenocorticism
Elevated ACTH
Low cortisol levels

Question 4

Cushing Disease

Answer 4

Hyperadrenocorticism
Elevated Cortisol
ACTH may be low or high (usually low)

Question 5

Addison Presentation

Answer 5

Non specific malaise, dizzy, nausea, abdominal pain, muscle cramps, hyper-pigmented skin, low libido, weight loss, salt craving, ‘chronic ill appearance’

Decreased body hair may occur, altered menses may occur

Severe symptoms during times of high stress / injury

Question 6

Cushing Presentation

Answer 6

Chronic changes
Weight gain, loss of menses, low libido, weakness, bruising, hypertension, glucose intolerance, memory issues, central obesity, ‘moon face’, skin striae, hair growth, emotional lability

Question 7

pheochromocytoma presentation

Answer 7

hallmark of pheochromocytoma is a new onset of moderate to severe hypertension, with systolic pressures above 170 mm Hg. Arrhythmias, sinus tachycardia, or bradycardia may be present

Question 8

Addison Diagnostics

Answer 8

Hyperkalemia, hyponatemia may occur
adrenal antibody studies
Rule out TB
Elevated ACTH, low Cortisol

Question 9

Cushing Diagnostics

Answer 9

100mcg of cortisol in urine over 24 hours
Single test may be viable if serum is over 7.5
ACTH Suppression testing by specialist

Question 10

Pheochromocytoma diagnostics

Answer 10

Elevated fractionated metanephrines in urine or plasma

Rule out toxic / drugs / other meds

Question 11

Mild Addison Mimicks

Answer 11

Eating disorders
Chronic fatigue syndrome
alcohol abuse
malnutrition
hyperthyroid
diabetes
Chronic wasting illness

Question 12

Cushing Mimics

Answer 12

Depression
Obesity
Polycystic ovary syndrome

Question 13

Common Cause of Cushing

Answer 13

Over-use or prolonged use of steroids

Question 14

Addison Management

Answer 14

Acute crisis needs ED admit for IV steroids
Chronic patients need oral hydrocortisone in divided daily doses to mimic natural pattern, may need to increase in times of stress

Question 15

Cushing Management

Answer 15

Stop steroids
Off-label use of ketoconazole as a P-450 competitor to mitigate cortisol effects
Patients need close follow-up for osteoporosis risks

Question 16

Pheochromocytoma Management

Answer 16

Surgical removal, anti-hypertensives like alpha-blockers until surgery
Beta blockers if tachycardia also occurs

Question 17

Referral Criteria

Answer 17

Suspicion of Addison, Cushing, or Pheochromocytoma

Addison Crisis requires ED referral

Question 18

Which test will the primary care provider order to diagnose a patient with new-onset hypertension with a systolic blood pressure of 180 mm Hg?

Cortisol excretion studies

Fractionated metanephrine levels

ACTH suppression testing

Adrenal antibody tests

Answer 18

Correct! Patients with pheochromocytoma may present with new-onset hypertension with systolic pressure >170 mm Hg. Fractionated metanephrine will be elevated when the diagnosis is confirmed.

Question 19

Primary v Secondary Addison

Answer 19

Primary adrenal insufficiency (Addison disease) is caused by pathology or disease of the adrenal gland

Secondary adrenocortical insufficiency, on the other hand, is a condition in which there is an insufficiency of adrenocorticotropic hormone (ACTH) which, in turn, prevents the body from producing enough cortisol

Question 20

Addison and Sodium

Answer 20

Cortisol acts on the kidneys to provide sodium reabsorption and potassium excretion. The low cortisol levels in Addison means patients will have low serum sodium and high serum potassium

Question 21

Nonpathologic factors on ACTH levels

Answer 21

Stress, diurnal variations, drugs, steroids