Cram The Pance - S1E3 Cushing vs. Addison

Episode Date: January 3, 2021

Cushing vs Addison in 12 minutes! All you need to know for the PANCE, PANRE and EOR’s!►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

So today we're going to be going over a couple high-yield topics, an endocrine for the pants, your panery, your EORs. We're going to go over Addison's and Cushings and a few things that you need to know for both of these. So let's start with chronic adrenocortico insufficiency. This is when the adrenal gland doesn't produce enough hormones, whether it's the adrenal gland that's failing or the pituitary, not producing enough ACTH. Either way, the adrenal gland is not producing sufficient hormones.

So there's a couple different causes. There's primary and secondary. When most people think of this, Most people think straight to Addisons, which is going to be a primary cause. But secondary is important as well. As far as etiology is the most common cause overall is going to be exogenous steroid use. So remember that. That's really important.

So starting with secondary. Secondary is actually going to be a lack of just cortisol. The aldosterone is okay because the adrenal gland is functioning fine. And secondary, the pituitary is actually failing and it's not producing enough ACTH. So ACTH is what controls cortisol production from the adrenals. So in this case, pituitary and secondary is not producing sufficient ACTH. As far as etiology, again, going back to exogenous steroid use, this is going to be the most common cause of secondary. Moving on to primary, which is, I'd say the more important of the two.

This is going to be Addison's disease. So this is going to be the adrenal gland destroyed for some reason, and it's not producing enough of the hormones that you need. Cortisol and aldosterone are the ones that are insufficient in this case. So primary Addison's disease is going to. to be adrenal gland failing, whereas secondary is going to be the pituitary. So in primary, which is Addison's disease, the adrenal gland is destroyed. The most common cause in the United States is going to be autoimmune causes. As far as developing countries, infection is going to be your most common cause.

So think of TB, HIV. And then medications can also cause Addison's as well. The big ones you should remember are ketocondisol and refampin. those are two big ones that I've seen a lot in the past on other exams. So remember, ketoconazole and refamping can both cause Addison's disease, but your most common cause here in the United States is going to be autoimmune causes. So there's a few things you should know about Addison's disease. And the way that I remember it is I break down the letters in Addison.

So ADD-I-S-O-N. We'll start with the A. A is going to stand for autoimmune disease, which is going to be your most common cause in the U.S. D, the first D in Addison is going to stand for drugs. So think of keto connoissell and refampin. The second D in Addison is going to stand for destruction of the adrenal gland, which is another cause. The I in Addison stands for infection. So think of TB, HIV, which again was the most common cause in developing countries.

The S in Addison's is going to stand for skin changes because due to the increased ACTH in Addisins, you can actually see hyperpigmentation of the skin because the increased ACTH stimulates melanocyte production. So remember, the S's skin changes. The O in Addison is going to be orthostatic hypotension. which can be caused due to the decreased aldosterone in Addisons. And then finally, the N in Addison's is going to stand for N-A or sodium decrease, hyponatremia, which can be seen in this as well. As far as the symptoms you can see in both, anorexia is common, nausea vomiting, salt craving,

hyponatremia, hypoglycemia. Sometimes they're just having some vague abdominal pain and they can actually have an adrenal cortical insufficiency. So as far as just Addisons, these symptoms will only be seen in Attecine's. medicines, and this is going to be the hyperpigmentation that I talked about, which is from the increased ACTAH, and then orthostatic hypotension, which is due to the decreased aldosterone that you see only in Addison's, again, because the adrenal gland is not working, so aldosterone is also affected. As far as the labs, the first thing that you want to do is go ahead and get their

ACT-H level. AC-T-H in primary is going to be increased, and that's because the adrenal glands not producing enough cortisol so the pituitary is responding appropriately and increasing the ACTAH. And secondary, it should be decreased because remember secondary is a pituitary failure, so the pituitary is not producing enough ACTH. So the way you test for this is an 8 a.m. A.c.H. This is going to be, or a first thing in the morning, ACTH level. Some other labs that you may test for that can be seen. You may do a finger stick and see hypoglycemia, hyponatremia, hypercalemia are all common. And then also it's also possible to have a non-anion gap metabolic acidosis.

And this is due to the decreased aldosterone in Addison's. So once you take your ACTAH, you want to go ahead and figure out, is this a primary or a secondary cause? And the way you can do this is to go ahead and give them something called cosynotropic. This is a synthetic ACTH. So you give them a high dose of cosynotropic. And if their serum cortisol rises, it's going to be secondary. So if you think of the pathophysiology behind it, it kind of makes sense.

because you're giving them a high dose of ACTAH. And if it were a primary cause, it doesn't matter how much ACTAH you give them. The adrenal's failing. It can't produce more cortisol. So it doesn't matter what the ACTH is telling the adrenal gland to do. It just can't do it. So remember that. Think about that.

But in secondary, the pituitary is failing. So it's not producing enough ACTH. So all the adrenal gland knows is I have a decreased ACTH, so I'm not going to produce more cortisol. But you go ahead and give them this high dose of cortisol, all of a sudden their cortisol level normalizes and it starts going up. So that would be a secondary cost. Remember that in screening. If you go ahead and you give them cosinotropic and their serum cortisol rises, it's secondary.

If there's no rise in the cortisol, you should be thinking that this is going to be a primary cause or Addison's. So as far as treatment, you need to know which it is, primary, secondary, because there's different ways to treat it. So if it's secondary, you're only going to give them hydrochortisone. Dexomethone is another option because their aldosterone is okay, so you only need to replace the cortisone. So the cortisol. So that's hydrochortisone. But if it's primary, Addisons, remember the adrenal cleanse failing, so you have a problem with the aldosterone as well, so you need to replace that.

So in primary, in addition to hydrochortizone, you're also going to give them fluguritone, which is similar to aldosterone. It regulates the blood pressure and sodium levels. So again, in secondary, only hydrochortizone, primary or addisons, you're going to give them hydrochortisone and flugercortisone. So let's move on to the complete opposite of this, which is. Cushing's syndrome. This is going to be an excess cortisol rather than the previously that we previously talked about was a deficiency. So Cushing's syndrome, cortisol excess, again, the most

common cause in this as well is going to be exogenous steroids. So also some endogenous causes that you should remember, they're not as common, but some of the endogenous causes, Cushing's disease is going to be pituitary gland increased ACTH production. So this is normally, due to a pituitary adenoma. And remember, Cushing's syndrome is not the same as Cushing's disease. Cushing's syndrome is just a general cortisol excess. But when we're talking about Cushing's disease, which is the primary cause, this is going to be the actual pituitary gland that has a problem and the ACTH is going to be increased. And that's going to be most likely to do it on adenoma. So some other causes of their endogenous causes, you can have an

A CTOH producing tumor. This is most likely when you see it in a vignette due to small cell lung cancer. Small cell lung cancer, remember, you can see this ACTH producing tumor. Don't forget that small cell lung cancers can cause increased ACTH body, increased ACTH in the body. Another cause is an adrenal tumor where you'll see an increased cortisol. The patient, the way they're going to be presenting, and I'm sure we've all seen this in pictures, the patient with Cushing's syndrome, It's going to be obesity, buffalo hump, thin extremities, moon face, striae, hypertension. They may have acanthosis negracans from the insulin resistance seen in the body. And then also due to the androgen excess in some cases, they may have oily skin, acne, hercetism,

which is that increased facial hair. So remember those. Those are really important and those are something that you almost always see in a vignette. It's very common to see that in Cushings. So as far as screening, there's a few ways when you want to screen. So the first thing you have a patient that comes in, you suspect they have some kind of cortisol excess. The first thing that you're going to do is you want to see how much cortisol is in the body to see if they do indeed have an excess. So the most specific way you can do it is with a 24-hour urine free cortisol.

So you can test the cortisol that way. You can also do a nighttime salivary cortisol. And then there's also a low dose overnight dexymethosone suppression test, which is, basically you give them one milligram of dexamethosone before they go to bed and then in the morning you check their you check their cortisol levels and if there's an increase or no suppression um with a low dose dexymethazone this is going to be Cushing syndrome um so the most common or the the most specific way again is going to be your 24 hour urine free cortisol and it's also one of the easier ways to do it um and remember there are other causes that you may see an increase in

cortisol. So you want to get the most specific test. Pregnancy can cause an increased cortisol infection, stress, all those things can cause your cortisol to increase. So once you see that they do have an increased cortisol in the body, you want to go ahead and differentiate. Is this from, is this from Cushing's disease or Cushing syndrome? So the way you're going to do that is you're going to get their baseline ACTH first to see if it's elevated or decreased. And then you're also going to give them, you're going to do an increased dose or dexymethosone suppression test, which is going to distinguish Cushing's disease, which is your pituitary cause from other causes. So in Cushing's disease, which is going to be

your pituitary cause, their ACTH is going to be increased and there will be a suppression of cortisol on high dose. So remember, the only one that's going to suppress, the only cortisol level that will suppress is going to be with Cushing's disease. So in Cushing's disease, you'll see an increased ACTAH and you're going to see suppression of cortisol on the high dose. If it's an ectopic ACTAH tumor, obviously your ACTAH will be increased on the labs, but there will be no suppression of cortisol. And then in an adrenal tumor, there will be decreased ACTAH and there will be no suppression. So again, ectopic ACTAH, adrenal tumor, no suppression in cortisol levels. The only one that's going to suppress on a high dose dexamethasone suppression test

is going to be Cushing's disease, which is a pituitary cause. So remember that. And then the ACTH makes sense in all of them. Obviously, in ectopic ACTH tumor, the ACTAH will be elevated and so on. But remember that Cushing's disease is the only one that will suppress. So as far as treatment, it depends on what the cause is. So if it's from steroid use, exogenous steroid use, you're going to gradually taper them off. If it's a pituitary adenoma, you can do a transatlantic.

spinoidal resection, which is actually an incision they make at the back of the nose. They enter into the spinoid sinus and they access the cell atersica to get to the pituitary and actually remove the adenoma. That's a pretty interesting surgery. You should look it up and actually see that surgery done. It's a less invasive way to do it. They can actually go through the nasal cavity or they can go through the top of the mouth to access the cellotersica and get to the pituitary.

And again, the other ones, it's all about just cutting it out if it's an adrenal tumor. cut it out. If it's an ectopic tumor, you can cut it out. Ketoconazole can actually be using in ectopic tumors as well to suppress that. But most of the time with Cushings, it's most likely going to be a pituitary adenoma. So you're going to do a transphenol resection. And then the other tumors as well, you're just going to cut it out. So they're probably not going to ask you many questions on treatment because it's pretty straightforward. And that's pretty much it. So I think that's a good review of the high yield things. that you should know for both Addison's and Cushings.

Remember some of those screening tests and the differentiating tests. I think those are important for you to know what the actual cause is, and that's definitely something they can test you on. So I hope that was helpful for you guys. Let me know if you have any questions, comments, anything you want me to do differently. Maybe I'm talking too fast or whatever it is. Just let me know in the comments. And if there's a topic you want me to do next, definitely let me know.

And I'm going to keep making these weekly. Just let me know what you think.