1. Diseases of the Adrenal gland

2. Adrenal insufficiency
Cushing disease vs syndrome
Pheochromocytoma
Hyperaldostronism

3. What are the layers of the adrenal gland
What are the layers of the adrenal gland ?? And what does each layer produce ??

4. What are the layers of the adrenal gland
What are the layers of the adrenal gland ?? And what does each layer produce ??

5. Adrenal insufficiency
What is adrenal insufficiency ?
What are the possible underlying causes ?
How many types of adrenal insufficiency exist and how do they differ?
How does it manifest ?
How is it treated ?

6. Adrenal insufficiency
A disorder caused by the destruction of the adrenal cortices
Causes :
The most common cause of adrenal insufficiency in adults is chronic exogenous steroid use ( how ???)
Autoimmune destruction accounts for 80% of the primary cases in the U.S
Other causes include congenital enzyme deficiencies
hemorrhage (Waterhouse-Friderichsen) TB
other infections
May be isolated or be a component of a polyglandular autoimmune syndrome

7. Presentation Symptoms Physical exam fatigue worsened by stress
weakness
weight loss
nausea and vomitting
Physical exam
increased skin pigmentation (due to elevated pro-opiomelanocortinin → MSH and ACTH)
hypotension

8. Labs :elevated plasma ACTH ( in primary adrenal insufficiency )
It is diagnosed by demonstrating a low basal serum cortisol level that does not increase appropriately after stimulation with the ACTH analogue cosyntropin .
decreased aldosterone leads to
hyponatremia
hyperkalemia
hypoglycemia
increased BUN & Cr
metabolic acidosis
eosinophilia

9. Treatment of adrenal insufficiency
Pateints with primary adrenal insufficiency require glucocorticoid and mineralocorticoid replacement , but those with central disease require glucocorticoid replacement only ,
WHY ???
Administer stress dose steroids at time of stress(surgery)

10. Cushing disease vs. syndrome
What are they ?
How do they differ ?
How do thy manifest ?
How are they diagnosed ? GOLD STANDARD ?
How are they treated ?

11. Cushing disease vs syndrome
A condition that refers a constellation of signs and symptoms caused by prolonged exposure to supraphysiologycal levels of glucocorticosteroids .
Iatragenic followed by ACTH secreating pituitary adenoma are most common causes .

12. Presentation
Symptoms
depression and psychological changes
oligomenorrhea
growth retardation
weakness
acne
excessive hair growth
symptoms of diabetes (polydipsia, polyuria, dysuria)
Physical exam
hypertension 
central obesity
muscle wasting
thin skin that easily bruises
purple striae
hirsutism
moon facies
buffalo hump

14. 1- 24 hour free urinary cortisol (GOLD STANDARD )
2-low-dose dexamethasone suppression test
(cortisol levels generally not suppressed in Cushing syndrome)
3-midnight salivary cortisol
Hyperglycemia hypokalemia and hypernatremia could also exist
 to localize lesion:
ACTH
high dose dexamethasone supression test
(cortisol levels suppressed if ACTH source is pituitary adenoma, but generally not if ectopic ACTH production)
CT and MRI to localize lesions
Inferior petrosal sinus sampling

16. For non resectable tumors:
Resection of source
For non resectable tumors:
ketoconazole (inhibits P450)
aminoglutethimide (inhibits P450)
metyrapone (blocks adrenal enzyme synthesis)
mitotane (adenolytic)

17. PRIMARY HYPRALDOSTERONISM
Excess production of aldosterone independent of the physiological regulator of its production ( WHICH IS ……..?)
MOST COMMON CAUSE IS ………..?

18. polyuria (secondary to hypokalemic nephropathy)
Symptoms hypertension (secondary to increased plasma volume secondary to increased sodium reabsorption)
Suspect the diagnosis in patients with resistant hypertension who develop severe hypokalemia after initiation of a thiazide diuretic (such as HCTZ)
headache
polyuria (secondary to hypokalemic nephropathy)
muscle weakness (secondary to hypokalemia)
Physical examtetany (hypokalemia)
parestesias
peripheral edema in severe cases
hypertension

19. hypokalemia
hypernatremia
low plasma renin (neg. regulation by high aldsterone)
metabolic alkalosis (dumping H+ for Na+)
HOW IS IT DIAGNOSED ????

20. Treatment Surgical adrenalectomy for adenoma
bilateral adrenalectomy should not be performed
Spirolactone or eplerenone (aldosterone receptor antagonist) for bilateral adrenal hyperplasia or bilateral adnomas

21. Pheochromocytoma Composed of which type of cells ??
What do they secrete ?
What are the know familial causes of these tumors ?
What are the possible sites for pheos ?
Is there a percentage of malignant pheos ?
How do they present , what is the classical triad of symptoms they produce ?
How are they diagnosed ? How are tumors localized?
How are they treated ?
What is the antihypertensive medication that is absolutely contraindicated to give on its own in pheos ?

22. Q1--A patient with lethargy, nausea, and reported muscle weakness is given a series of tests to rule out physical causes.  During these tests it is revealed that plasma corticotropin is above normal and cortisol is below normal.  Renin is above normal and aldosterone is below normal.  Adrenal androgens are below normal. Which of the following clinical conditions would be most likely to produce this set of signs and symptoms?

23. A. Cushing’s Disease
B. Ectopic corticotropin-producing tumor
C. Secondary renal insufficiency
D. Congenital adrenal hyperplasia
E. Addison’s Disease

24. Q2--A 48 YO man with a family history of heart disease has followed a heart- healthy lifestyle for 15 years.  However, he has recently experienced unusual fatigue and lightheadedness, especially when rising suddenly. Physical examination demonstrates postural hypotension and a darker-than usual complexion for midwinter in the Midwest (he works and exercises indoors).  Lab work reveals that he is hyponatremic, hyperkalemic, and hypocalcemic.  Further blood tests are ordered to assay plasma corticotropin-releasing hormone (CRH), corticotropin (ACTH), and cortisol. What combination of hyper and/or hyposecretion for these hormones would be the most likely given this man’s signs and symptoms?  

25. CRH secretion ACTH secretion Cortisol secretion
A- hypersecretion hypersecretion hypersecretion
B- hypersecretion hypersecretion hyposecretion
C -hypersecretion hyposecretion hyposecretion
D- hyposecretion hyposecretion hyposecretion
E- hyposecretion hyposecretion hypersecretion

26. Q3--A 47-year-old male has been feeling fatigued and has gained 20 pounds during the last two months. On exam, you note central obesity with proximal muscle atrophy and weakness. Vital signs are as follows: T 98.4 F, BP 155/90 mmHg, HR 85 bpm, RR 14 rpm. BMP is as follows: Na 140, K 3.9, Cl 102, CO2 23, BUN 19, Cr 0.9, Glu hour urinary free cortisol level is 165 nmol/day (upper range of normal nmol/day) and morning serum ACTH is 83 pg/mL (normal is pg/mL). Two days later, he receives a high-dose 2 mg dexamethasone suppression test orally every 6 hours for 48 hours. The following morning at 9 am, his serum cortisol level is 300 nmol/L (normal is nmol/L). At 48 hours it is 250 nmol/L. Which of the following should be the next step?

27. 1-Bilateral inferior petrosal sampling
2-Initiate treatment with metyrapone
3-Initiate treatment with ketoconazole
4-CT of the thorax and abdomen
5-Brain MRI

28. Q4--A 69-year-old presents with granulomatosis with polyangiitis (formerly Wegener's) diagnosed about 8 months ago. He was treated with rituximab and prednisone for induction remission and has required prednisone since his diagnosis. Her temperature is 37 deg C (98.6 deg F), pulse is 80/min, blood pressure is 150/90 mmHg, respirations are 14/min, and O2 saturation is 99% on room air. His physical examination is notable for the findings in Figures A and B. What would be the most likely electrolyte abnormality found in this patient?

30. 1-Hypokalemia and hyponatremia
2-Hyperkalemia and hypernatremia
3-Hypokalemia and hypernatremia
4-Hyperkalemia and hyponatremia
5-Hypercalcemia and hypernatremia

31. Q6--A patient with chronic obstructive pulmonary disease is admitted to the hospital with cholecystitis. He undergoes cholecystectomy uneventfully and is transferred to the floor. Suddenly, he becomes weak and severely hypotensive. If the patient's symptoms are due to adrenal insufficiency from chronic steroid use, one would expect which of the following
1-Elevated renin
2-Elevated cortisol
3-Decreased ACTH
4-Elevated ACTH
5-Elevate aldosterone

32. Q7----A 37-year-old female presents to general medical clinic with headache, fatigue, and weakness. She also reports that she has been having to get up at night to urinate. She has no significant past medical history. She denies taking any medications. Her vital signs are stable with the exception of blood pressure of 165/100. Physical examination is unremarkable. She is concerned because she never remembers having high blood pressure. A workup of the patient's hypertension is initiated, and it is found that she has an elevated plasma ratio of aldosterone to renin. Which of the following would also be likely in this patient? 1-Metabolic acidosis 2-Hyperkalemia 3-Hyperglycemia 4-Metabolic alkalosis 5-High renin levels

33. A 56-year-old male with a history of difficult-to-control hypertension presents to his physician with progressive fatigue and new onset muscle cramps. He has had no recent changes to his medication regimen, which includes hydrochlorothiazide, lisinopril and amlodipine. His physical exam is notable for a blood pressure of 170/100 but is otherwise within normal limits. A routine basic metabolic panel demonstrates the following lab values:  Sodium: 147 mEq/L  Potassium: 2.6 mEq/L Chloride: 102 mEq/L HCO3: 26 mEq/L BUN: 13 g/dL Creatinie: 0.7 mg/dl Glucose: 98

34. What is the mechanism causing the patient's elevated blood pressure?
1-Adrenal hemorrhage
2-Cortisol excess
3-Stress
4-Medication toxicity
5-Excess sodium retention