Pearls from Dr. Salila Kurra
- ACTH --> stimulates gluccocorticoids and lack of ACTH can lead to hypotension and secondary adrenal crisis/insufficiency. As ACTH doesn't affect mineralocorticoids as much, Na/K are often not affected
- TSH --> Causes central hypothyroidism with low TSH and low FT4; assays for FT3 less reliable.
- GH --> Check IGF1 as well (age-adjusted). Needs replacement in children for growth but replacement in adults is more controversial given expense, may improve QOL
- FSH/LH --> Will lead to low testosterone in men that can be symptomatic, can replace as an outpatient
- Prolactin --> Can check to rule out prolactinoma, which would affect treatment
Posted 06/14/16 10:32:50 AM by Ying Liu
Treatment for Pan-Hypopituitarism and Adrenal Crisis
- Steroid replacement with either hydrocortisone (two doses given in morning and ~2pm, 10mg/5mg is a common dose) or prednisone (5mg for women/7.5mg for men) daily.
- Synthroid for hypothyroidism.
- For young healthy patients, start with 1.6x weight in Kg (112mcg of synthroid is typical dose for 70kg man)
- For patients >65, start at 50mcg daily if no CAD risk factors or 25mcg daily if CAD risk factors
- During sickness or times of stress, would triple steroid replacement to compensate. If unable to tolerate PO, would refer to the ED for IV steroids.
- Important to give steroids before synthroid to avoid adrenal crisis as hyperthyroidism is protective in adrenal insufficiency
Posted 06/14/16 10:42:28 AM by Ying Liu
Central Diabetes Insipidus (DI)
- Hypernatremia with extremely dilute urine as there is no ADH to stimulate aquaporins in the collecting ducts to retain free water (mechanism)
- Can diagnose central DI with Water Deprivation Test with subsequent dosing of 4mcg of ddAVP --> expect to initially see dilute urine that concentrates with ddAVP if central DI
- If intact thirst, can just increase intake of free water or give free water prescription
- If no thirst given neurosurgery, can give intra-nasal ddAVP
Posted 06/14/16 10:55:24 AM by Ying Liu
For further reading...
Posted 06/14/16 10:58:22 AM by Ying Liu
- If >4cm, presumed to be malignant and needs further evaluation
- Need to consider whether it is functioning or not
Posted 10/10/16 11:45:56 AM by Adam Faye
Adrenal Mass - Must rule our Pheochromocytoma
- Serum Metanephrines have high sensitivity
- Do NOT start beta Blockers until Pheo is ruled out. Would not use alpha/beta blockers either, because generally block beta receptors more than alpha- leaving unopposed alpha blockade.
- Classic story from Pheo- often hear excessive diaphoresis
Posted 10/10/16 11:57:25 AM by Adam Faye
- Generally see hypertension and hypokalemia
- Labs generally show; suppressed Renin & Aldo >15. Typically Aldo/Renin ratio >20. Usually test AM sample, and have patient off mineralocorticoid receptor antagonists (eg: spironolactone) or ACEi/ARBs.
- Low K+ can cause aldosterone levels to appear lower
Posted 10/10/16 12:01:52 PM by Adam Faye
**Do NOT biopsy Adrenal Carcinoma, as it can seed other sites***
- Adjuvant Mitotine for treatment of adrenocrtical carcinoma may prolong recurrence-free survival
Posted 10/10/16 01:33:12 PM by Adam Faye
25% of one adrenal gland is all that is needed for normal functioning.
Posted 10/10/16 01:37:02 PM by Adam Faye
Posted 10/10/16 02:33:53 PM by Adam Faye
Phun Pheo Phacts
- diaphoresis = very common chief complaint of patients presenting with new diagnosis of pheochromocytoma
- hypertension in patients with pheos = episodic, episodes are short, thus it is common not to see sequelae of high blood pressure on EKG, TTE, etc.
- metanephrines 3-4x the upper limit of normal is high enough for a pheo
- up to 50% of patients with pheochromocytoma have genetic syndromes
- MEN2 - any patient with medullary thyroid cancer must be evaluated and ruled out for pheo prior to thyroidectomy, relation to ret oncogene
- von Hippel-Lindau
Posted 12/20/16 09:50:15 AM by Anna Krigel
Of the secondary causes of hypertension:
- Hyperaldosteronism - more common, BMP can show low Na, low K, and high bicarb, though hypokalemia is a not a sensitive finding as a high percentage of patients with hyperaldo can present without hyperkalemia
- Cushing's - less common than hyperaldo, do not see hypokalemia unless there is an ectopic source of ACTH
Posted 12/20/16 09:53:16 AM by Anna Krigel
- larger than 4 cm are always either malignant or a pheochromocytoma, typically >20 Hounsfield units on CT with delay of washout of contrast
- these masses should never be biopsied as if they are malignant (adrenocortico carcinoma) then biopsy can seed the abdomen with malignant cells
Posted 12/20/16 10:05:09 AM by Anna Krigel
- start alpha-blocker first, do not start beta blocker or combined beta/alpha blocker (e.g. carvedilol, labetalol) to avoid unopposed alpha effect
- not using phenoxybezamine nearly as often due to adverse effect of orthostasis in many patients as well as nasal congestion
- now favoring any other alpha blocker, doxazosin commonly being used
- can add on beta blocker prior to surgery for tachycardia
- recommend volume expansion in days leading up to surgery with high dietary salt intake to avoid post-operative hypotension
- surgical adrenalectomy - can be done laparoscopically
Posted 12/20/16 10:13:46 AM by Anna Krigel
Pheochromocytoma Rule of 10s
- 10% extra-adrenal
- 10% of non-familial pheos are bilateral
- 10% malignant
- 10% arise in childhood
- 10% present without hypertension
Posted 12/20/16 10:15:59 AM by Anna Krigel
Pericardial effusion: reported in 30% to 80% of subjects with hypothyroidism
- Usually associated with severity of disease
- Tamponade rare as effusions typically slow growing and rarely large
- Responsive to thyroid hormone replacement
Posted 03/02/17 09:13:20 AM by Matthew Cummings
Severe hypothyroidism and risk of adrenal insufficiency
- Primary hypothyroidism --> risk of primary AI; secondary hypothyroidism --> hypopituitarism and secondary AI.
- Potential risk of precipitating acute adrenal insufficiency caused by the accelerated metabolism of cortisol that follows T4 therapy.
- Send AM cortisol, low threshold for stress dose hydrocortisone
Posted 03/02/17 09:19:30 AM by Matthew Cummings
For further reading...
Posted 03/02/17 09:22:20 AM by Matthew Cummings
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