Page 59 Complete Your CE Test Online - Click Here who undergo bilateral adrenalectomy, or who develop an adrenal gland thrombosis[5,11,25] . Signs and symptoms of adrenal crisis include[5,25] : ● ● Significant weakness and fatigue. ● ● Abrupt severe pain in the lower back, abdomen, or legs. ● ● Severe nausea and vomiting. ● ● Dehydration. ● ● Hypotension. ● ● Loss of consciousness. Untreated adrenal crisis can lead to vascular collapse, renal shutdown, coma, and death. Patients need to receive an emergency bolus of hydrocortisone followed by fluid resuscitation. Patients should carry an emergency kit with a corticosteroid injection with them at all times. They and their families and friends should be taught how to administer the injection[25] . Mark has a real weakness for black licorice, and eats large quantities of it. Eating large amounts of black licorice can cause signs and symptoms that mimic what disease? Why does this occur? Eating large amounts of English black licorice or licorice-like substances can cause a syndrome that mimics primary hyperaldosteronism. This is because glycyrrhizic acid, a substance found in licorice, has a mineralocorticoid action[5] . Why is diabetes mellitus often found in conjunction with hyperaldosteronism? Diabetes mellitus is frequently found in conjunction with hyperaldosteronism because hypokalemia, which causes the majority of clinical effects of hyperaldosteronism, can interfere with proper secretion of insulin. What electrolyte imbalance is strongly linked to a diagnosis of hyperaldosteronism? Ongoing low levels of serum potassium in patients who do not have edema, are not taking diuretics, have not had GI tract losses due to vomiting or diarrhea, and who have a normal sodium intake strongly suggest hyperaldosteronism[5] . What saline suppression test results would you expect to find in patients who have hyperaldosteronism? Patients are given intravenous salt solutions after which blood levels of aldosterone and renin are measured. In patients with primary hyperaldosteronism the level of aldosterone in the blood is still high, and the level of renin is low even after this salt loading[27] . In cases of primary hyperaldosteronism, what results would you expect the 24-hour urinary excretion of aldosterone test to show? Patients ingest a high-sodium diet for five days after which the amount of aldosterone in the urine is measured. In patients with primary hyperaldosteronism, aldosteronism will not be suppressed by the salt load, and the level of aldosterone in the urine will be high[27] . Cushing’s syndrome is a hormonal disorder caused by prolonged exposure of the body’s tissues to excessive levels of adrenocortical hormones, especially cortisol, related corticosteroids, and, to a lesser extent, androgens and aldosterone[5, 28] . Differentiate between Cushing’s syndrome and Cushing’s disease. If excess of glucocorticoids is due to a pituitary dependent condition, it is called Cushing’s disease[11] . What groups of people may have high levels of cortisol not related to pathological processes? Since cortisol helps the body to respond to stress, pregnant women in the last three months of pregnancy and highly trained athletes have high levels of this hormone[28] . Differentiate among the three types of Cushing’s syndrome. Cushing’s syndrome can be categorized as three types[11] : ● ● Primary: Primary Cushing’s syndrome is due to disease of the adrenal cortex. ● ● Secondary: Secondary Cushing’s syndrome is caused by hyperfunction of cells that secrete corticotropin in the anterior pituitary gland. ● ● Tertiary: Tertiary Cushing’s syndrome is due to dysfunction or injury of the hypothalamus. Differentiate between Cushing’s syndrome and cushingoid syndrome. Differentiating between Cushing’s syndrome and cushingoid syndrome can be challenging. Chronic depression, alcoholism, and long-term treatment with corticosteroids can combine to produce cushingoid syndrome, an adverse consequence characterized by fat deposits between the shoulders and around the waist and many systemic abnormalities. Cushing’s syndrome has similar signs, but can be differentiated from cushingoid syndrome by the additional presence of hypertension, renal problems, hyperglycemia, muscle weakness, tissue wasting, and frequently changing emotional states (emotional lability) [5] . Complete this sentence. In Cushing’s syndrome immune system suppression can mask_____________. Immune system suppression can mask infection, even severe infections [5] . It is important for HCP to recognize, and to teach patients and families to recognize, even the slightest signs of infection. Describe how radiation therapy is used to treat Cushing’s syndrome. If surgical approaches fail, or if a patient is not a candidate for surgery, radiation therapy is a possible alternative treatment. Radiation treatment to the pituitary gland is generally administered over a six-week period. Improvement is noted in 40% to 50% of adults and up to 85% of children[28] . It may take months or even years for patients to feel better after receiving radiation treatment alone. Radiation in conjunction with cortisol-inhibiting drugs can help speed up the recovery process[28] . In Cushing’s syndrome, patients with non-endocrine corticotropin- producing tumors require excision of the tumor followed by drug therapy. Drug therapy is also administered in the event that patient cannot undergo surgery. One of the drugs used is Lysodren. How does Lysodren work? Mitotate (Lysodren) is toxic to the adrenal cortex. Its administration is referred to as medical adrenalectomy. Side effects of this drug include nausea, vomiting, diarrhea, somnolence, and depression. Adrenogenital syndrome, perhaps more commonly known as congenital adrenal hyperplasia, is a syndrome caused by disorders of adrenocortical steroid biosynthesis. Most cases of the syndrome are due to the failure of the adrenal glands to produce enough cortisol [5,29] . Inherited adrenogenital syndrome is referred to as congenital adrenal hyperplasia (CAH). Which is the more severe form of CAH? What are its clinical manifestations? The salt-losing form of CAH is more severe than the simple form and causes more complete virilization in females. Male external genitalia (but without testes) develop[5,29,30] . Males with salt-losing CAH have no abnormalities in external genitalia. Thus, diagnosis immediately after birth is difficult and usually delayed until severe signs and symptoms develop. In severe cases signs of salt-losing CAH infants may develop as soon as two to three weeks after birth in both males and females. These signs include vomiting, diarrhea, dehydration, low potassium and sodium levels, and abnormal heart rhythms[29, 30] . Infants are apathetic and fail to eat. These signs indicate the onset of adrenal crisis, which, unless treated promptly, may lead to cardiovascular collapse and cardiac arrest[5] . What does adrenal crisis or evidence of adrenal hypofunction in the first week of life suggest? Adrenal crisis or evidence of adrenal hypofunction in the first week of life suggests salt-losing CAH[5] . Define hermaphroditism. Hermaphroditism is a condition appropriately mentioned as part of a discussion of CAH. Hermaphroditism is a rare condition in which children have both ovarian and testicular tissues. External genitalia are usually ambiguous, but may also be completely male or female, which effectively “hides” hermaphroditism until puberty. The child with hermaphroditism almost always has a uterus and ambiguous gonads. Fertility, however, is rare[5] .