Medicine I > Hyperadrenocorticism > Flashcards

Hyperadrenocorticism Flashcards

(46 cards)

Study These Flashcards
1
Q

OBJ: Understand adrenal gland functional anatomy and regulation

A
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2
Q

OBJ: Know the common clinical signs of hyperadrenocorticism (HAC)

A
  • PU/PD
  • normal to increased appetite
  • panting, restless, anxiety
  • Cushingoid body type
    • pendulous distended abdomen
    • muscle wasting
    • thin coat
    • multiple dermatologic lesions
      • thin skin
      • comedones
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3
Q

OBJ: Understand the two most common types of HAC (PDH and ADH)

A
  • Pituitary Dependent Hyperadrenocorticism
    • Pituitary
    • Adenoma
    • 85% of cases
    • bilateral enlargement of adrenal size due to hyperplasia
  • Adrenal Dependent Hyperadrenocorticism
    • adrenal gland
    • adenoma or adenocarcinoma
    • 15% of cases
    • Unilateral enlargement
      • contralateral atrophy
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4
Q

OBJ: Understand common screening and differentiating test for HAC

A
  • Screening
    • UCCR
    • LDDST
    • ACTH
  • Differentiating
    • Adrenal US
    • Endogenous ACTH measurement
    • HDDST
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5
Q

OBJ: Know treatment options for PDH and ADH

A
  • PDH
    • hypophysectomy
    • Medical management
      • anti-adrenal therapy
      • pituitary therapy
    • Radiation
  • ADH
    *
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6
Q

OBJ: Review/Understand Pertinent aspects of feline HAC

A
  • PDH
    • hypophysectomy
    • Medical management
      • anti-adrenal therapy
      • pituitary therapy
    • Radiation
  • ADH
    • Adrenalectomy
    • Anti-adrenal therapy
      • Trilostane
      • Lysodren
      • Ketoconazole
      • Anipryl
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7
Q

How is cortisol secretion regulated?

A
  • Regulated through the Hypothalamic Pituitary Adrenal Axis (HPAA)
    • See Image
  • ACTH secretion is pulsatile
    • Influenced by:
      • Feeding
      • Physiologic / environmental stress
        • Pain
        • Trauma
        • Hypoxia
        • Pyrogens
        • Cold exposure
        • Surgery
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8
Q

What is the difference between PDH and ADH?

A
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9
Q

What is the common signalment of hyperadrenocorticism in dogs?

A
  • Any breed
  • Median age of diagnosis is 10-11yr
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10
Q

What are the clinical signs of Hyperadrenocorticism?

A
  • Dogs with HAC generally feel and act well
  • PU/PD - almost all dogs with HAC
  • Appetite normal to increased
  • Panting, restlessness, anxiety
  • ‘Cushingoid’ body type
    • pendulous and distended abdomen
    • muscle wasting
    • thin coat
    • multiple dermatologic lesions
    • thin skin
    • comedones
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11
Q

What neurologic signs are common in hyperadrenocorticism dogs?

A
  • signs caused by macroadenoma (10-15% PDH cases)
  • Anorexia
  • behavioral changes
  • disorientation
  • blindness
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12
Q

What Cardiovascular effects are common in hyperadrenocorticism dogs?

A
  • Hypertension
  • Thromboembolism (hypercoagulable)
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13
Q

What musculoskeletal problems are common in hyperadrenocorticism dogs?

A
  • Poor body condition
  • muscle loss
  • cruciate rupture
  • myopathy
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14
Q

What reproductive signs are common in hyperadrenocorticism dogs?

A
  • decrease in testicular androgen production in males
  • Anestrus in females
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15
Q

What findings are common on diagnostic imaging in dogs with hyperadrenocorticism

A
  • Hepatomegaly
  • Adrenal tumor
  • Focal calcification
  • Lung mineralization
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16
Q

What CBC findings are common in hyperadrenocorticism dogs?

A
  • Anemia is uncommon
  • Stress leukogram - neutrophilia, lymphopenia
  • Thrombocytosis
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17
Q

What Serum Chemistry findings are common in hyperadrenocorticism dogs?

A
  • Elevated liver enzymes (ALP > ALT)
    • ALP - GC induced isoenzyme
    • ALT - vacuolar hepatopathy
  • Hypercholesterolemia
  • Hyperglycemia (mild)
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18
Q

What urinalysis findings are common in hyperadrenocorticism dogs?

A
  • Low urine specific gravity <1.020
  • Proteinuria
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19
Q

How is hyperadrenocorticism diagnosted?

Study These Flashcards
A
  • 2 step approach
    • Screening tests - confirm adrenal hypersecretion
      • Urine cortisol:creatinine ratio (UCCR)
      • Low does dexamethasone suppression test (LDDST)
      • ACTH stimulation test
    • Differentiating tests - distinguish PDH and ADH
      • Adrenal US (or other dx imaging)
      • endogenous ACTH measurement
      • High dose dexamethasone suppression test (HDDST)
20
Q

What do the results of a Urine Cortisol : Creatinine Ratio (UCCR) test mean?

Study These Flashcards
A
  • Dogs with HAC have elevated urine cortisol:creatinine ratio
  • normal results rule out HAC - high specificity
  • Abnormal result require confirmation with another screening test
21
Q

What do the results of a Low Dose Dexamethasone Suppression Test (LDDS) mean?

Study These Flashcards
A
  • Effective screening test
  • can be a differentiating test
  • dogs with HAC have elevated 8-hr cortisol
  • Stress / Nonadrenal illness = False +
22
Q

What do the results of a ACTH stimulation Test mean?

Study These Flashcards
A
  • Generally considered more Specific than LDDS
  • Dogs with HAC have elevated post-ACTH cortisol
  • Cannot distinguish between PDH and AT
23
Q

What Hyperadrenocorticism screening test is a good choice if non-adrenal illness is suspected?

Study These Flashcards
A

ACTH Stimulation test

24
Q

What do the results of a High Dose Dexamethasone Suppression Test (HDDST) mean?

Study These Flashcards
A
  • Suppression = PDH
    • 70% of PDH cases suppress - can differentiate from AT
    • 30% of PDH cases do not suppress
  • No Suppression = AT
25
What doe the results of an Endogenous ACTH Test (eACTH) mean?
* Low = AT * High = PDH * Diagnostic in \>80% of dogs (\>95% when re-tested)
26
Compare and contrast Hyperadrenocorticism tests
27
What imaging techniques are useful for diagnosing PDH?
* CT, MRI, and US * Pituitary tumor (macroadenoma or smaller) * only 50% of PDH have detectable ass * Bilateral adrenal hypertrophy (uniform / nodular) * normal and abnormal glands overlap in size
28
What imaging techniques are useful for diagnosing ADH?
* US, CT * Unilateral adrenal enlargement (usually nodular change) * Atrophy of contra-lateral gland * Not every adrenal mass is functional - possible misdiagnosis if functional testing is not done
29
What are the treatment options for PDH?
* Hypophysectomy * Surgical * removal/destruction of adenoma * Difficult * Medical Management * Anti-adrenal therapy * Pituitary Therapy * Radiation * Reserved for macroadenoma * Slows tumor growth * less effect on abnormal hormone production
30
What is an Adrenalectomy?
* Preferred treatment for ADH * Pre-op imaging - asses metastasis and local invasion * May require pre-surgical stabilization * Peri- and post-operative complications * Hemorrhage * Thromboembolism * Adrenal insufficiency * Prognosis * good is tumor is benign and easily removed * malignant tumors = less favorable prognosis
31
What medications are available to treat hyperadrenocorticism?
* Trilostane * Lysodren * Ketoconazole * Anipryl
32
How does Trilostane work to treat HAC?
* Inhibits synthesis for adrenal cortical steroids * Reversible inhibitor of 3B-hydroxysteroid dehydrogenase
33
What is the dose of Trilostane? Adverse effects?
* 2 - 4 mg/kg/day (divided BID) * Incremental increase as needed * Minimal Adverse Effects: * Transient vomiting, diarrhea and lethargy * Rarely, hypoadrenocorticism may develop * Acute adrenal necrosis (rare
34
How can trilostane therapy be monitored for effectiveness?
* **ACTH stimulation test** * 10 - 14 days after starting * 2 weeks after dose increase * q3 months for the long term * Target post-ACTH of 1.45 - 5.4 ug/dl * up to 9.1 ug/dl is acceptable if clinical signs are controlled * **Post-dose cortisol concentration** * sample 4 - 6 hr post-dose. * Cortisol ≥ 1.3 ug/dl excludes excessive suppression * ≤ 2.9 excludes grossly inadequate control * **Pre-dose Cortisol** * pre-trilostane cortisol of 1.4 - 5 ug/dl correlates with effective control of clinical signs but not with post-ACTH stim cortisol concentrations
35
How does Lysodren work to control HAC?
* “mitotane” * **Adrenocorticolytic** that acts by destruction of functional adrenal tissue * Occasionally used as alternative to trilostane
36
How does Ketoconazole work to control HAC?
* Reversible inhibition of adrenal steroidogenesis (primarily glucocorticoids)
37
How does Anipryl control HAC?
* “selegiline' ‘L-deprenyl’ * Monoamine oxidase inhibitor (MAO) - reduces ACTH production
38
What is the Prognosis of HAC?
* PDH * goal - improved quality of life * CNS signs carry guarded prognosis * ADH * Benign adrenal tumors - good/excellent prognosis if removed * Malignant tumors - guarded to poor prognosis due to local tissue invasion
39
Do cats suffer from hyperadrenocorticism?
* Considered uncommon to rare * \>80% have PDH * ~50% have microscopic pituitary tumors * Iatrogenic - less common than dogs * Differentials include DM and acromegaly
40
What is the common signalment of cats with HAC?
* Middle age or older (average - 10 yr) * Higher incidence in females (70%) * 80% of cats have insulin resistance and diabetes
41
What are the common clinical signs of Feline HAC?
* PU/PD * polyphagia * Diabetes that is “difficult to regulate” * weight loss / failure to gain weight * Lethargy; look ill * Skin fragility * alopecia * failure to groom * pendulous abdomen
42
What laboratory findings are common with Feline HAC?
* Limited Database * CBC - no consistent abnormalities * Serum chemistry * hyperglycemia * ALP not increased * cats lack GC - induced ALP isoform * Urinalysis * Spec Gravity usually \<1.020 * Glucosuria
43
How is Feline HAC diagnosed?
* Screening test - same as Canine HAC * ACTH stimulation test * LDDS Test * use 0.1 mg/kg (vs 0.01 mg/kg in dog) * UCCR * Differential testing - same as Canine HAC * HDDS test * Use 1.0mg/kg (0.1mg/kg in the dogs) * Abdominal ultrasound * Endogenous ACTH levels
44
What is the treatment for Feline ADH?
* Surgery best option if metastatic disease/invasion absent
45
What is the treatment for Feline PDH?
* Treatment of choice is controversial * Surgery - Bilaeteral adrenalectomy * Hypophysectomy * Radiation Therapy * Medical Therapy * mitotane - cats more resistant * Trilostane - limited information * Ketoconazole - cats more resistant
46
What is the prognosis for Feline HAC?
guarded to poor
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