https://www.nature.com/articles/s41574-018-0058-5
2. Answer: C
The patient is likely to have a diagnosis of adrenal crisis with symptoms of nausea, vomiting, hypotension, severe lethargy, weakness, altered mental state, hyponatraemia, hyperkalaemia, and a known history of adrenal insufficiency. Her low BP suggests that she has adrenal crisis with haemodynamic instability, rather than adrenal insufficiency. Septic shock can clinically mimic adrenal insufficiency with symptoms of hypotension, fever, and gastrointestinal symptoms, thus it is important not to miss either the diagnosis of sepsis or adrenal crisis and initiate appropriate investigations and treatment. Administration of appropriate dosage of corticosteroids is imperative to avoid adverse sequalae.
In patients with vomiting and diarrhoea, administration of 100 mg IV hydrocortisone initially is recommended followed by IV hydrocortisone 100 mg qid then 50 mg qid the next day until it is safe to change to oral hydrocortisone after 24 hours. Oral hydrocortisone is usually prescribed at 2 to 3 times the normal oral hydrocortisone dose, with a gradual taper back to the patient's regular dose over the following 2 to 3 days. Administration of oral fludrocortisone is not required if the initial hydrocortisone doses exceed 50 mg over 24 hours for patients with primary adrenal insufficiency as high doses of hydrocortisone will exert mineralocorticoid activity. Oral fludrocortisone can be resumed once the patient is able to have oral hydrocortisone.
Biochemical abnormalities observed in patients with adrenal crisis include hyponatraemia, hyperkalaemia, hypercalcaemia, hypoglycaemia, neutropenia, lymphocytosis, eosinophilia, and mild normocytic anaemia. IV fluid resuscitation with 0.9% normal saline 1L within the first hour is recommended. If the patient is hypoglycaemic, intravenous dextrose 5% in normal saline is given.
It is important for patients with a medical history of adrenal insufficiency and adrenal crisis to have a sick day plan and ongoing education about the condition. Without appropriate recognition and treatment of adrenal crisis, patients may potentially take longer to diagnose, leading to poorer outcomes. MedicAlert bracelets, necklaces, easy access to intramuscular hydrocortisone, oral corticosteroid medications, ambulance services and hospitals are important measures to prevent subsequent adrenal crisis in patients with past history of adrenal crisis or insufficiency.
Rushworth R, Torpy D, Falhammar H. Adrenal Crisis. New England Journal of Medicine. 2019;381(9):852–861.
3. Answer: D
An ‘adrenal incidentaloma’ is an adrenal mass, greater than 1 cm in diameter, that is found serendipitously when a patient undergoes a radiological examination for reasons unrelated to adrenal disease. There has been an increased incidence of ‘adrenal incidentalomas’ due to the widespread use of CT and MRI. The prevalence of adrenal incidentalomas during autopsies ranges from 1 to 9% and increases with increasing age.
Most adrenal tumours are non‐hypersecreting, benign adrenocortical adenomas. Adrenal masses, such as cortisol‐secreting adrenocortical adenoma, unilateral or bilateral congenital adrenal hyperplasia, pheochromocytoma, adrenocortical carcinoma, and metastatic carcinoma, are also frequently described. Metastases to the adrenal glands are usually bilateral; primary malignancies that are commonly associated with adrenal metastasis include carcinoma of the lung, kidney, colon, breast, oesophagus, pancreas, liver, and stomach.
Focused history taking and clinical examination is important to rule out functioning and malignant adrenal tumours to diagnose the underlying medical conditions, e.g. Cushing's syndrome, pheochromocytoma, primary aldosteronism, adrenocortical carcinoma, and metastatic cancer.
In patients with a positive overnight dexamethasone (1 mg) suppression test, that is a morning serum cortisol >139 nmol/L, confirmatory tests including serum corticotropin, 24‐hr urine cortisol collection, midnight salivary cortisol, and a formal 2‐day high‐dose dexamethasone suppression test, are required to establish the diagnosis of Cushing's syndrome.
The size of the adrenal tumour does not affect recommendations regarding biochemical testing. However, adrenal tumours that are greater than 4 cm in diameter raise concern for potential primary adrenocortical malignancy.
Due to its high cost and a greater (FDG‐PET) uptake in a small percentage of benign adrenal lesions compared to the background uptake, PET scans are not routinely recommended to evaluate patients with adrenal incidentaloma without a history of malignancy.
Image‐guided fine‐needle aspiration (FNA) biopsy is generally not recommended to differentiate between adrenal vs non‐adrenal tissues (metastases or infection), due to risks associated with possible biopsy of a phaeochromocytoma or seeding of metastasis. It is important to biochemically rule out pheochromocytoma before considering performing an FNA biopsy of the adrenal mass due to the potential hypertensive crisis and bleeding complications associated with pheochromocytoma.
Young W. The Incidentally Discovered Adrenal Mass. New England Journal of Medicine. 2007;356(6):601–610.
https://www.nejm.org/doi/full/10.1056/NEJMcp065470
4. Answer: C
Amiodarone, is a potent class III antiarrhythmic drug and an iodine‐rich compound with a molecular structure similar to thyroxine (T4) and triiodothyronine (T3). It has a long half‐life (107 days), which allows effects to occur months after stopping treatment. Therapeutic doses of amiodarone contain much more iodine (up to 50–100 times), than the recommended daily iodine intake and significantly increases systemic and thyroidal iodine pools. Amiodarone can cause changes in thyroid function tests and serious thyroid dysfunction, such as amiodarone‐induced hypothyroidism (AIH) and type I and type II amiodarone‐induced thyrotoxicosis (AIT 1 and AIT 2, respectively) in patients with or without underlying thyroid disease.
AIH does not require cessation of amiodarone and is easily managed. In patients with overt hypothyroidism second to AIH, levothyroxine replacement is recommended. In patients with subclinical hypothyroidism, patients will require ongoing monitoring of the thyroid function; treatment is only required if there is overt hypothyroidism.
The diagnosis of AIT requires increased serum FT4 and FT3 and suppressed serum TSH levels. Anti‐thyroid antibodies, such as anti‐thyroid peroxidase antibodies, are often positive in AIT 1 and negative in AIT 2.
The clinical presentation of AIT is variable and there is poor correlation between the clinical findings and biochemical severity of the condition. Extreme weight loss and myopathy may indicate life‐threatening thyrotoxicosis.
AIT 1 occurs in patients with pre‐existing multinodular goitre or latent Graves’ disease. The excess iodine from amiodarone provides increased substrate, resulting in enhanced thyroid hormone production. Treatment of AIT 1 includes antithyroid therapy with thionamides (carbimazole or propylthiouracil) that may be combined for a few weeks with sodium perchlorate to make the thyroid gland more sensitive to thionamides.
AIT 2 results from direct toxic effect on the thyroid cells by amiodarone causing thyroiditis in a normal thyroid gland without increased hormone synthesis