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Approach to Adrenal Disorders

Approach to Adrenal Disorders. Abdallah Al Marzouki, M.D. Adrenal Disorders. Incidental adrenal mass: Diameter less than 1 cm Common, prevalence 10% incidentally, routinely found (C.T., MRI) 85% non functioning Adenoma (benign) 5% functional Tu (active tumor of Adrenal

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Approach to Adrenal Disorders

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  1. Approach to Adrenal Disorders Abdallah Al Marzouki, M.D.

  2. Adrenal Disorders Incidental adrenal mass: Diameter less than 1 cm Common, prevalence 10% incidentally, routinely found (C.T., MRI) 85% non functioning Adenoma (benign) 5% functional Tu (active tumor of Adrenal cortex, producing cortisol, aldosteron or androgen.

  3. Adrenal Disorders Incidental adrenal mass: Patient asymptomatic Management: Functional lesions and Tu > 4 cm (surgery) Non functioning lesions < 4 cm, treat if increased in size or become active.

  4. A 58-year-old woman comes to the office after a near-fainting spell she experienced 1 day ago. She was outside playing tennis when she vomited and felt lightheaded. She spent the rest of the day lying down with mild, diffuse, abdominal pain and nausea. She had no fever or diarrhea. She reports several months of worsening fatigue. Mild, intermittent, generalized abdominal pain, and loss of appetite with a 10 to 15 lb unintentional weight loss.

  5. Her medical history is significant for hypothyroidism for which she takes levothyroxine. She takes no medications. On examination, her temperature is 99.8°F, heart rate 102 bpm, blood pressure 89/62 mmHg, and normal respiratory rate. She does become lightheaded and her heart rate rises to 125 bpm upon standing with a drop in systolic blood pressure to 70 mmHg.

  6. She is alert and well tanned, with hyperpigmented creases in her hands. Her chest is clear, and her heart rhythm is tachycardiac but regular. On abdominal examination, she has normal bowel sounds and mild diffuse tenderness without guarding. Her pulses are rapid and thready. She has no peripheral edema. Initial laboratory studies are significant for Na 121 mEq/L, K 5.8 mEq/L, HCO3 16 mEq/L, glucose 52 mg/dl, and creatinine 1.0 mg/dl.

  7. What is the most likely diagnosis?

  8. Primary adrenal insufficiency

  9. What is your next step?

  10. Draw blood for cortisol level Give IV NS + stress doses of corticosteroid

  11. Objectives Know the presentation of primary and secondary adrenal insufficiency and of adrenal crisis. Know the most common causes of primary and secondary adrenal insufficiency. Know the treatment of adrenal insufficiency

  12. Clinical Pearls Primary adrenal insufficiency presents with weakness, fatigue, abdominal pain with vomiting, hyperpigmentation and hyponatremia with hypotension which may be refractory to pressors. Treatment of adrenal crisis is immediate administration of salt (saline), sugar (glucose) and steroids (hydrocortisone)

  13. Clinical Pearls The most common causes of primary adrenal insufficiency in the United States are autoimmune destruction, metastatic disease, and infectious causes (eg, cytomegalovirus in advanced acquired immunodeficiency syndrome). The most common cause worldwide is tuberculosis.

  14. Clinical Pearls Secondary adrenal insufficiency is the most common form of the illness and usually is a result of suppression of the hypothalamic-pituitary axis by exogenous corticosteroids.

  15. Question A 53-year-old woman is brought to the ED by her husband, who states that she is feeling very weak over the last 2 days, is nauseated and vomiting at least three times. The husband states that his wife was talking a high dose medication for her joint pain but ran out of her pills last weeks.

  16. Question (cont) Her vital signs are BP of 90/50 mm Hg, HR 87 beats per minute, RR 16 breaths per minute, and temperature 98.1°F. You place her on monitor, begin IV fluid and send her blood to the laboratory. Thirty minutes later metabolic panel results are back and reveal the following: Na 126 mEq/L, K 5 mEq/L, Cl 99 mEq/L, HCO3 21 mEq/L, BUN 24 mg/dl, Creatinine 1.6 mg/dl, Glucose 69 mg/dl, Ca 11 mEq/L

  17. Question (cont) What is the most likely diagnosis? Myxedema coma Thyroid storm Hyperaldrosteronism Adrenal insufficiency Diabetic Ketoacidosis (DKA)

  18. The answer is D Adrenal cortical insufficiency is a uncommon, potentially life-threatening condition that if recognized early, is readily treatable. The most common cause of adrenal insufficiency is hypothalamic-pituitary-adrenal axis suppression from longterm exogenos glucocorticoid administration.

  19. This patient abruptly stopped her high dose steroids. The clinical presentation of adrenal insufficiency is vague but typically includes weakness, fatigue, nausea, vomiting, hypertension and hypoglycemia. Electrolyte abnormalities are common. Hyponatremia and hyperkalemia are present in more than two-thirds of cases. Management includes supportive care with administration of glucocorticoids and electrolyte correction.

  20. (a and b) Myxedema coma is a syndrome of extreme hypothyroidism, whereas thyroid storm is extreme hyperthyroidism. (c) Hyperaldosteronism is characterized by hypertension and hypokalemia. (e) DKA typically presents with elevated glucose, an anion-gap metabolic acidosis and ketone production.

  21. THANK YOU...

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