____________________________________

____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________

HIPOADRENOCORTICISMO
____________________________________
____________________________________

”SINDROME DE ADISSON”
____________________________________
____________________________________
____________________________________
ENDOCRINOLOGIA ____________________________________
____________________________________
• MSC. GUSTAVO DITTRICH ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
DEFINIÇÃO ____________________________________
____________________________________
____________________________________
____________________________________
Diminuição da secreção adrenocortical ____________________________________
(glicocorticoides e mineralocorticoides) ____________________________________
____________________________________
____________________________________
____________________________________
Cortisol

X
____________________________________
____________________________________
Retém Na+ ____________________________________
Aldosterona ____________________________________
____________________________________
Elimina K+ ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
CAUSAS ____________________________________
____________________________________
____________________________________

»Hipoadrenocorticismo primário ____________________________________

____________________________________
____________________________________
»Imunomediado Mais comum! ____________________________________
»Idiopático 90% ____________________________________
____________________________________
»Iatrogênico (mitotano, trilostano) ____________________________________
____________________________________
____________________________________
____________________________________
»Hipoadrenocorticismo secundário ____________________________________
____________________________________
»Neoplasia em hipófise ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
SINAIS CLÍNICOS ____________________________________
____________________________________
____________________________________
____________________________________
»Apatia, fraqueza ____________________________________
____________________________________
»Anorexia ____________________________________
»PU/PD ____________________________________

»Êmese e diarreia ↓Na+ ____________________________________

____________________________________
____________________________________
»Tremores ____________________________________
»Emagrecimento ____________________________________
____________________________________
»Desidratação
↑K+ ____________________________________
»Hipotensão ____________________________________
____________________________________
»Bradicardia ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
DIAGNÓSTICO ____________________________________
____________________________________
____________________________________
»Resenha, anamnese, exame físico ____________________________________
____________________________________
»Exames laboratoriais ____________________________________
____________________________________
»Hemograma: linfocitose, eosionofilia ____________________________________
____________________________________
»Bioquímica sérica ____________________________________
____________________________________
» Azotemia pré-renal ____________________________________
» Hiponatremia e hipercalemia ____________________________________
» Na/K < 27!!! ____________________________________
____________________________________
» Hipoglicemia ____________________________________
»Urinálise: baixa densidade urinária ____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
DIAGNÓSTICO ____________________________________
____________________________________
____________________________________
____________________________________
»Outros exames ____________________________________
____________________________________
»Eletrocardiografia: bradiarritmia (↑K+) ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
»Radiografia torácica: microcardia ____________________________________
____________________________________
»Ultrassonografia: ↓ adrenais ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
DIAGNÓSTICO ____________________________________
____________________________________
____________________________________
____________________________________
»Função adrenal ____________________________________
____________________________________
»Cortisol após teste de estimulação ____________________________________
____________________________________
com ACTH ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
0 h 1 h ____________________________________
Cortisol basal Cortisol 1h após ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
TRATAMENTO ____________________________________
____________________________________
____________________________________
____________________________________
»Crise Addisoniana (emergência!) ____________________________________
____________________________________
»Fluidoterapia sem potássio ____________________________________
____________________________________
»Solução fisiológica (NaCl 0,9%) ____________________________________
____________________________________
»Glico e mineralocorticoide ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
TRATAMENTO ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Composto Potência Potência
Glicocorticóide Mineralocorticóide ____________________________________
____________________________________
Ação Rápida ____________________________________
Hidrocortisona 1,0 1,0 ____________________________________
Cortisona 0,8 0,8 ____________________________________
____________________________________
Ação Intermediária
____________________________________
Prednisolona 4,0 0,8 ____________________________________
Prednisona 4,0 0,8 ____________________________________
Metilprednisolona 5,0 Mínima ____________________________________
Triancinolona 5,0 Zero ____________________________________
____________________________________
Ação Lenta ____________________________________
Dexametasona 30 Mínima ____________________________________
Betametasona 30 Indeterminada ____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
TRATAMENTO ____________________________________
____________________________________
____________________________________
____________________________________
»Crise Addisoniana (emergência!) ____________________________________
____________________________________
»Fluidoterapia sem potássio ____________________________________
____________________________________
» Solução fisiológica (NaCl 0,9%) ____________________________________
____________________________________
»Glico e mineralocorticoide ____________________________________
» Hidrocortisona ____________________________________
____________________________________
» Dexametasona ____________________________________
____________________________________
»Tratamento sintomático ____________________________________
» Ranitidina, ondansetrona, dipirona... ____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
TRATAMENTO ____________________________________
____________________________________
____________________________________
____________________________________
»Manutenção (em casa) ____________________________________
____________________________________
»Fludrocortisona ____________________________________
____________________________________
» 10 a 30 μg/Kg VO, 24 hrs ____________________________________
____________________________________
»Prednisona ____________________________________
» 0,2 a 0,5 mg/Kg VO, 24 hrs ____________________________________
____________________________________
____________________________________
____________________________________
»Desoxicorticosterona (DOCP) ____________________________________
» 2,2 mg/Kg IM, 25 dias ____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
DISCUSSÃO DE CASO CLÍNICO ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
RESENHA ____________________________________
____________________________________
____________________________________
____________________________________
» Cão, fêmea, castrada, 8 anos, SRD, 8 Kg ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
ANAMNESE ____________________________________
____________________________________
____________________________________
____________________________________
» Apatia e prostração ____________________________________
____________________________________
» Emagrecimento (1-2 Kg em 7 dias!) ____________________________________
____________________________________
» Hiporexia ____________________________________
____________________________________
» Tremores ____________________________________
» PU/PD ____________________________________
____________________________________
» Nega êmese, diarreia, tosse, espirro, secreção ____________________________________
____________________________________
ocular ou nasal. ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
EXAME FÍSICO ____________________________________
____________________________________
____________________________________
____________________________________
§ Mucosas normocoradas ____________________________________
____________________________________
§ TPC 3 segundos ____________________________________
____________________________________
§ Aumento do turgor de pele Desidratação ____________________________________
____________________________________
§ Ressecamento de mucosa moderada ____________________________________
§ Enofltamia discreta ____________________________________
____________________________________
____________________________________
§ Sopro grau III/VI foco mitral ____________________________________
____________________________________
____________________________________
§ Palpação abdominal: sem dor, ausência de ____________________________________
organomegalia ____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
PATOLOGIA CLÍNICA ____________________________________
____________________________________
____________________________________
____________________________________
» Hemograma - Eritrograma, PP e plaquetas ____________________________________
____________________________________
Parâmetros Valor Referência
Parâmetros Valor Referência ____________________________________
Eritrócitos 7,31 milhões/mm3 5,5 – 8,5 milhões/mm3 ____________________________________
Eritrócitos 7,31 milhões/mm3 5,5 – 8,5 milhões/mm3 ____________________________________
Hemoglobina 15,1 g/dL 12 – 18 g/dL ____________________________________
Hemoglobina 15,1 g/dL 12 – 18 g/dL ____________________________________
Hematócrito 48% 37-47% ____________________________________
Hematócrito 48% 37-47%
____________________________________
VGM 65,66 fL 60-77 fL
VGM 65,66 fL 60-77 fL ____________________________________
CHGM 32,46% 32-36% ____________________________________
CHGM 32,46% 32-36% ____________________________________
Proteína plasmática 10,6 g/dL 6-8 g/dL ____________________________________
Proteína plasmática 10,6 g/dL 6-8 g/dL
____________________________________
Plaquetas 404.000 200.000 – 600.000 ____________________________________
Plaquetas 404.000 200.000 – 600.000
____________________________________
Desidratação
 ____________________________________
____________________________________
____________________________________
____________________________________
PATOLOGIA CLÍNICA ____________________________________
____________________________________
____________________________________
____________________________________
» Hemograma - Leucograma ____________________________________
____________________________________
Parâmetros Valor Referência
____________________________________
Leucócitos totais 9.800 6.000 – 17.000 ____________________________________
____________________________________
Neutrófilos segmentados 5.390 3.000 – 11.500 ____________________________________
____________________________________
Neutrófilos bastonetes 0 0 – 300 ____________________________________
Metamielócitos 0 0 ____________________________________
____________________________________
Linfócitos 2.744 1.000 – 4.800 ____________________________________
Eosinófilos 588 100 – 1.250 ____________________________________
____________________________________
Monócitos 1.078 150 – 1.350 ____________________________________
Basófilos 0 Raros ____________________________________
____________________________________
Nada digno de nota
 ____________________________________
____________________________________
____________________________________
____________________________________
BIOQUIMICA SÉRICA ____________________________________
____________________________________
____________________________________
Parâmetro Valor Referência ____________________________________
____________________________________
Albumina 2,74 g/dL 2,6 – 3,3 g/dL ____________________________________
ALT 34 UI 0 – 102 UI ____________________________________
____________________________________
Creatinina 2,07 mg/dL 0,5 – 1,5 mg/dL
____________________________________
Fosfatase Alcalina 108 UI 20 – 156 UI ____________________________________
____________________________________
Glicemia 88 mg/dL 70-110 mg/dL ____________________________________
____________________________________
Ureia 69 mg/dL 20 – 60 mg/dL
____________________________________
Sódio (Na+) 144 mmol/L 145 – 151 mmol/L ____________________________________
____________________________________
Potássio (K+) 6,8 mmol/L 3,9 – 5,1 mmol/L ____________________________________
____________________________________
Cloro (Cl-) 110 mg/dL 109 – 122 mg/dL ____________________________________
____________________________________
Azotemia Hiponatremia Hipercalemia
 ____________________________________
____________________________________
____________________________________
____________________________________
URINALISE ____________________________________
____________________________________
____________________________________
Exame físico Valor Exame Valor ____________________________________
químico ____________________________________
Cor Amarelo claro
____________________________________
Glicose Negativo
Aspecto Turvo ____________________________________
Corpos ____________________________________
Volume 12 mL Negativo
cetônicos ____________________________________
Densidade 1,018 pH 6,0 ____________________________________
____________________________________
Sedimentoscopia Valor Sangue Negativo ____________________________________
Céls. descamação do Bilirrubina Negativo ____________________________________
Negativo
trato urinário Proteína Negativo ____________________________________
Bactérias Negativo ____________________________________

Leucócitos Negativo
Diminuição da ____________________________________
____________________________________
Hialinos raros e densidade ____________________________________
Cilindros ____________________________________
Granulosos raros
urinária ____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
IMAGEM ____________________________________
____________________________________
____________________________________
» Ultrassonografia abdominal ____________________________________
____________________________________
____________________________________
____________________________________
» Rins e bexiga ____________________________________
____________________________________
» Fígado e baço ____________________________________
____________________________________
Sem ____________________________________
» Estômago, alças intestinais ____________________________________
alterações ____________________________________
____________________________________
» Adrenais e pâncreas ____________________________________
____________________________________
____________________________________
» Linfonodos ____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
IMAGEM ____________________________________
____________________________________
____________________________________
____________________________________
» Ultrassonografia abdominal ____________________________________
____________________________________
» - Vesícula biliar: estrutura ecogênica em lume, ____________________________________
margens irregulares, aderida a parede, 0,7 cm ____________________________________
____________________________________
de diâmetro ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
IMAGEM ____________________________________
____________________________________
____________________________________
»Ecocardiografia ____________________________________
____________________________________
____________________________________
» DIAGNÓSTICO ____________________________________
____________________________________
» - Endocardiose de mitral com insuficiência ____________________________________
moderada. ____________________________________
» - Hipocinesia miocárdica difusa leve. ____________________________________
____________________________________
____________________________________
» OBSERVAÇÕES: A diminuição da contratilidade ____________________________________
pode estar associada a condições sistêmicas que ____________________________________
liberem citocinas, reduzindo a contratilidade ____________________________________
miocárdica. ____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
IMAGEM ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
PATOLOGIA CLÍNICA ____________________________________
____________________________________
____________________________________
____________________________________
» Bioquímica sérica ____________________________________
____________________________________
____________________________________
» Na = 144 ____________________________________
____________________________________
» K = 6,8 ____________________________________
____________________________________
» Relação Na:K (Na/K) = 144/6,8 = 21 ____________________________________
____________________________________
Normal: Na/K > 27 ____________________________________
Hipoadreno ____________________________________

corticismo Anormal: Na/K < 27 ____________________________________

____________________________________
____________________________________
Sugestivo: Na/K < 17 ____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
DOSAGEM HORMONAL ____________________________________
____________________________________
____________________________________
Teste de estimulação com ACTH ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
0 hrs 1 hr ____________________________________
Coleta de sangue para dosagem de Coleta de sangue para ____________________________________
cortisol e aplicação de ACTH ____________________________________
dosagem de cortisol
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
DOSAGEM HORMONAL ____________________________________
____________________________________
____________________________________
- ____________________________________
____________________________________
Hipotálamo ____________________________________
____________________________________
CRH ____________________________________
____________________________________
Feedback - ____________________________________
Hipófise ____________________________________
____________________________________
ACTH ____________________________________
____________________________________
____________________________________
Adrenal ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
CORTISOL
 ____________________________________
____________________________________
____________________________________
____________________________________
TESTE DE ESTIMULAÇÃO ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
DIAGNÓSTICO DEFINITIVO ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________

»Hipoadrenocorticismo ____________________________________
____________________________________
____________________________________

»ou
____________________________________
____________________________________
____________________________________
____________________________________
»Síndrome de Addison ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
TRATAMENTO ____________________________________
____________________________________
____________________________________
____________________________________
» Emergencial: ____________________________________
→ Fluidoterapia: ____________________________________
____________________________________
- NaCl 0,9%: correção da desidratação + ____________________________________
manutenção ____________________________________
____________________________________
→ Corticosteroide de ação rápida ____________________________________
- Hidrocortisona: 0,5 mg/Kg/h (infusão ____________________________________
contínua) ou 5 a 20 mg/Kg (a cada 6 hrs) ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
TRATAMENTO ____________________________________
____________________________________
____________________________________
____________________________________
Composto Potência Potência ____________________________________
Glicocorticóide Mineralocorticóide ____________________________________
____________________________________
Ação Rápida
____________________________________
Hidrocortisona 1,0 1,0 ____________________________________
Cortisona 0,8 0,8 ____________________________________
____________________________________
Ação Intermediária ____________________________________
Prednisolona 4,0 0,8 ____________________________________
____________________________________
Prednisona 4,0 0,8 ____________________________________
Metilprednisolona 5,0 Mínima ____________________________________
Triancinolona 5,0 Zero ____________________________________
____________________________________
Ação Lenta ____________________________________
____________________________________
Dexametasona 30 Mínima
 ____________________________________
____________________________________
____________________________________
____________________________________
TRATAMENTO ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
TRATAMENTO ____________________________________
____________________________________
____________________________________
____________________________________
» Manutenção ____________________________________
» Fludrocortisona ____________________________________
____________________________________
» 10 a 30 μg/Kg VO , 24 hrs ____________________________________
» Prednisona ____________________________________
» 0,2 a 0,5 mg/Kg VO , 24 hrs ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
EVOLUÇÃO ____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
 ____________________________________
____________________________________
____________________________________
____________________________________
PROGNÓSTICO ____________________________________
____________________________________
____________________________________
____________________________________

BOM!
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________