1. Disorders of the
Adrenal Glands
Patrick Carter MPAS, PA-C
Clinical Medicine I
March 25, 2011

2. Objectives
Describe the anatomy and physiology of the adrenal
glands Discuss the anatomical and embryological
relationship of the adrenal cortex contrasting with
the adrenal medulla
List and describe which hormones are produced in the
adrenal glands, factors influencing their production
and secretion
For each of the hormones produced by the adrenal
glands, describe their effects on the metabolism of
the body
Describe Cushing’s syndrome, discussing its:
Differentiation from Cushing’s disease
Etiology
Signs and symptoms
Diagnostic tests
Significant historical and physical exam findings
Management

3. Objectives
For Cushing’s syndrome and disease,
identify the outcomes of inappropriate
or inadequate treatment
Discuss how to suspect and diagnose
Conn’s Disease or hyperaldosteronism and
the significance of hypoaldosteronism
For Addison’s Disease, describe the
epidemiology, risk factors, signs and
symptoms, significant historical and
physical exam findings, pathophysiology,
diagnostic work-up and management
For Addison’s Disease, identify the
outcomes of inappropriate or inadequate
treatment

4. Anatomy

5. Adrenal Blood Supply

6. STRESSES such as:
• Heat/Cold
• Emotional Issues
• Trauma
• Infection
stimulate the
Hypothalamus to produce
corticotropin releasing factor
(CRF)
which stimulates the
Anterior pituitary to release
adrenocorticotropin
hormone (ACTH)
which causes the
Adrenal glands to produce
and release cortisol

7. HPA Axis Animation

8. Daily Cortisol

9. What does Cortisol do??
Actions are directed at enhancing the
production of high-energy fuel
(glucose) and reducing all other
metabolic activity not directly
involved in that process
Antagonizes the secretion and actions of
insulin
Promotes hepatic gluconeogensis
Inhibits inflammation
Suppress the immune response

10. Adrenal Crisis
Considerations
Causes weakness, abdominal pain, fever,
confusion, nausea, vomiting, diarrhea
Associated with hypotension,
dehydration, hyperpigmentation
High Potassium, Low Sodium, High BUN
Inability to elevate serum Cortisol
An emergency caused by
insufficient cortisol

11. Adrenal Crisis
Causes
Rapid withdrawal of steroids from
pts with adrenal atrophy owing to
chronic steroid administration
(most common)
Intensification of chronic
adrenal insufficiency that may be
rapid and overwhelming
Usually precipitated by sepsis or
surgical stress

12. Adrenal Crisis
Causes (cont’d)
Acute hemorrhagic destruction of
both adrenal glands
Newborns - bilateral adrenal
hemorrhage from birth trauma
Children – associated with
septicemia with Pseudomonas or
meningococcemia
Adults – trauma, anticoagulant
therapy or a coagulation disorder
(bilateral adrenal hemorrhage)

13. Adrenal Crisis
Causes (con’t)
Following sudden destruction of
pituitary gland
Pituitary necrosis
Thyroid hormone given to a patient
with hypoadrenalism
Following bilateral adrenalectomy or
removal of functioning adrenal tumor

14. Adrenal Crisis
Signs and symptoms
Headache, lethargy
N/V, abdominal pain, and diarrhea
Confusion or coma
Fever, as high as 40.6°C or more
Low blood pressure
Dehydration
Recurrent Hypoglycemia symptoms

15. Adrenal Crisis
Laboratory
Elevated Eosinophil count
Hyponatremia, Hyperkalemia,
Elevated BUN and BUN/Cr ratio
Positive Blood Cultures if caused by
infection
Cortisol is protein bound so if low
albumin check serum free cortisol level
Differential Diagnosis
Must be distinguished from other forms of
shock

16. Adrenal Crisis
Treatment
Immediately pull labs including cortisol
level
Treat immediately with bolus hydrocortisone
100 mg IV with D5NS
Continue hydrocortisone 10mg/h or 100mg
bolus q6h
Following improvement, the steroid dosage
is tapered over the next few days to
maintenance levels and add fludrocortisone
Broad-spectrum antibiotics given
empirically

17. Adrenal Crisis
Complications
Shock and death if untreated
Prognosis
Rapid treatment usually
lifesaving
Lack of treatment leads to shock
that is unresponsive to volume
replacement and vasopressors,
resulting in death

18. Addison’s Disease
Considerations
Weakness, fatigability, anorexia,
weight loss, N/V/D, abdominal pain,
myalgia, arthralgia, amenorrhea
Sparse axillary hair, hyperpigmentation
of creases, pressure areas, nipples
Hypotension
Hyponatremia, Hyperkalemia,
Hypercalcemia, Elevated BUN and BUN/Cr
ratio, Neuropenia, Mild Anemia,
Eosinophilia, Lymphocytosis

19. Addison’s Disease
Further Considerations
Results from progressive autoimmune
destruction of the adrenals (80% in US)
May be part of Polyglandular Autoimmune
Syndrome
Tuberculosis outside of US where it is
common
Bilateral adrenal hemorrhage
Adrenoleukodystrophy
>90% of the glands must be involved before
adrenal insufficiency appears

20. Addison’s Disease
Signs and symptoms
Onset is variable and manifestations vary
from mild chronic fatigue to fulminating
shock
Weakness and fatigue
Anorexia, nausea and vomiting, weight loss
Irritability and restlessness
Hypotension
90% have BP <110/70mmHg
Hypoglycemia, when present, may worsen
weakness and mental functioning

21. Addison’s Disease
Signs and symptoms
In diabetics, increased insulin
sensitivity and hypoglycemic reactions
Cutaneous and mucosal pigmentation
Diffuse brown, tan or bronze
darkening of elbows, creases of hand
or areolae
Bluish-black patches on the mucous
membranes
Scant axillary and pubic hair as well as
amenorrhea

23. Addison’s Disease
Laboratory Tests
Early in the disease labs may be
normal
More advanced stages of destruction
result in:
Hyponatremia (90%)
Hyperkalemia (65%)
Fasting blood glucose may be low
Hypercalcemia (10-20%)

24. Addison’s Disease
Diagnosis
Low plasma cortisol at 8am
Cosyntropin stimulation test
Synthetic ACTH (cosyntropin), 250 μg, given
parenterally (IM or IV)
Serum cortisol obtained 30 - 60 min later
Normally, cortisol rises to >20 μg/dL
For patients taking steroids, hydrocortisone
must not be given for at least 8 h before the
test
Other corticosteroids do not interfere with
specific assays for cortisol (predisone,
decadron)

25. Addison’s Disease
Diagnosis
DHEA > 1000 ng/ml RULES OUT
diagnosis
Serum DHEA
(Dihydroepiandrosterone)
levels are <1000 ng/ml in 100%
of patients with Addison’s
disease (not much help 15%
normal patients also)

26. Addison’s Disease
Imaging studies (if diagnosis not
clear)
Chest x-ray for TB, fungal infection, or
cancer
Abdominal CT
Small noncalcified adrenals in autoimmune
Addison's disease
Adrenals enlarged in about 85% of cases of
metastatic or granulomatous disease
Calcification noted in cases of tuberculosis
(~50%), hemorrhage, fungal infection, and
melanoma

27. Addison’s Disease
Medications – glucocorticoid and
mineralocorticoid replacement required
Hydrocortisone (cortisol)
Drug of choice
Usually 15-30 mg/d
Take with food
Want to simulate normal diurnal
adrenal rhythm
2/3 of dose is taken in the morning
1/3 taken in the late afternoon

28. Addison’s Disease
Medications
Dose adjusted according to clinical
response
Corticosteroid dose increased in cases of
infection, trauma, surgery, diagnostic
procedures, or other stress
Mineralocorticoid
Fludrocortisone 0.05–0.3 mg PO once daily
Maintain ample intake of sodium (3-4g/d)
Assess adequacy by measuring BP and serum
electrolytes (should be normal)

29. Addison’s Disease
Medications
DHEA 50 mg PO daily may
improve loss of muscle mass
and reverse bone loss and aid
in symptom relief
Use prescription form, OTC
unreliable dosing

30. Addison’s Disease
Follow-Up
Follow clinically and adjust
corticosteroid and (if required)
mineralocorticoid doses
Fatigue often persists despite
treatment but may indicate
Suboptimal dosing of medication
Electrolyte imbalance
Concurrent problems, such as
hypothyroidism or diabetes mellitus

31. Addison’s Disease
Complications
Adrenal crisis may be
precipitated by infection
Associated autoimmune
diseases are common
Excessive corticosteroid
replacement can cause
Cushing's syndrome

32. Addison’s Disease
Prognosis
Most patients able to live fully active
lives
Life expectancy is normal if adrenal
insufficiency is diagnosed and treated
Corticosteroid and mineralocorticoid
replacement must not be stopped
Patients should wear medical alert bracelet
Higher doses of corticosteroids must be
administered to patients with infection,
trauma, or surgery to prevent adrenal
crisis

33. Hypercortisolism
AKA Cushing’s
Cushing's "disease"
Pituitary tumor that produces ACTH hypersecretion
Cushing's "syndrome"
refers to manifestations of excessive
corticosteroids
Rarely spontaneous
Cushing’s disease (most common)
Autonomous secretion of cortisol by adrenals
(unilateral adrenal tumor)
Unknown ACTH secretion source
Nonpituitary ACTH secreting neoplasms (small cell
lung cancer)

34. Hypercortisolism
Signs and symptoms
Central obesity with thin
extremities (“moon facies” or
“buffalo hump”)
HTN
Fatigue and weakness
Osteoporosis
Females –acne, hirsutism,
oligomenorrhea or amenorrhea
Males – impotence

35. Hypercortisolism

36. Hypercortisolism
Signs and symptoms
Insulin resistance and
impaired glucose tolerance
Skin
Acne
Purple striae
Easy bruising, impaired wound
healing

37. Hypercortisolism
Signs and symptoms
Mental symptoms
Diminished concentration
Irritability
Depression
Psychosis
Increased susceptibility to
opportunistic infections

38. Hypercortisolism

39. Hypercortisolism
Differential Diagnosis
Chronic alcoholism (alcoholic pseudo-
Cushing's syndrome)
GHB Abuse “Party Drug”
Diabetes mellitus
Depression (may have hypercortisolism)
Osteoporosis due to other cause
Obesity due to other cause
Primary hyperaldosteronism

40. Hypercortisolism
Laboratory Tests
Glucose tolerance impaired - hyperglycemia
CBC - leukocytosis
Hypokalemia particularly with ectopic ACTH
secretion
Dexamethasone suppression test
Initial screening test
Administer 1 mg of dexamethasone orally at 11PM
Obtain serum cortisol level at 8 AM next
morning
Cortisol level < 2 mcg/dL excludes Cushing's
syndrome with 98% certainty

41. Hypercortisolism
Laboratory Tests
24 Hour urine for free cortisol
Order if dexamethasone suppression test shows
cortisol level >2 mcg/dL
>50μg/d helps confirm hypercortisolism
Increased: Pregnancy, Carbamazepine, Fenofibrate
If Cushing’s syndrome is confirmed
Obtain plasma ACTH
<20 pg/ml indicates probable adrenal tumor
>60 pg/ml ACTH indicates pituitary or ectopic ACTH-
secreting tumors

42. Hypercortisolism
Imaging Studies
If patient thought to have
hypersecretion of pituitary ACTH
Pituitary MRI with gadolinium contrast
If patient thought to have adrenal tumor
CT scan of the abdomen is best
CT scan of the chest can help locate source
of ectopic ACTH in lungs or thymus
Fails to detect the source of ACTH in about
40% of patients with ectopic ACTH secretion
Somatostatin receptor scintigraphy – occult
tumors

43. Hypercortisolism
Treatment
Pituitary Adenoma
Transsphenoidal resection or Gamma Knife
Adrenal Neoplasms
Resected Laparoscopically
Metastatic – mitotane, ketoconazole, etc.
If unable to locate
Laparoscopic bilateral adrenalectomy
Watch for cortisol withdrawal syndrome
Hypotension, nausea, fatigue, myalgias, etc.

44. Hypercortisolism
Prognosis
Benign Adrenal Adenoma & Pitutitary Adenoma
5-year survival 95%
10-year survival 90%
Ectopic ACTH secreting tumors
Varies based on tumor type and location
ACTH secretion unknown source
5-year survival 65%
10-year survival 55%
Adrenal carcinoma
Live only for 7 months

45. Woman who had undergone subtotal
adrenalectomy – picture taken 6 months
post procedure.
So what did this woman have –
Cushing’s Disease or Syndrome?

46. Primary Aldosteronism
Considerations
HTN that maybe drug resistant
Hypokalemia
Polyuria, Polydipsia
Muscle weakness
Elevated plasma and urine
aldosterone levels
Low plasma renin level

47. Primary Aldosteronism
Hypersecretion of aldosterone
Etiology
A benign unilateral adrenal adenoma (Conn’s
Syndrome) [Most Common Cause]
Unilateral or Bilateral hyperplasia of adrenals
Adrenal carcinoma (rare)
Epidemiology
Very common accounting for 5-10% all cases HTN
Affects women more than men (2:1 ratio)
Peak years of occurrence from age 30-60

48. Primary Aldosteronism
Signs and symptoms
Hypertension (typically moderate and
diastolic)
Hypokalemia due to renal loss
Polyuria, polydipsia
Muscle weakness (episodic paralysis)
Fatigue
Parasthesias
Headache

49. Primary Aldosteronism
Should be suspected in all
patients with HTN,
especially if
Low serum potassium
HTN is difficult to control
(>2 meds needed)
Family history of endocrine
tumor

50. Primary Aldosteronism
Laboratory findings
Serum Electrolytes
Hypokalemia (37%)
Hypernatremia - infrequent
Metabolic alkalosis - may be
present with an elevated serum
bicarb

51. Primary Aldosteronism
Laboratory findings (cont’d)
Aldosterone to Plasma Renin Assay
ratio
If ratio < 24 – excludes primary
aldosteronism
If ratio >30
Order 24-hour urine collection
which is assayed for aldosterone,
free cortisol, and creatinine
Low PRA (< 5mcg/L/h) with an elevated urine
aldosterone (>20 mcg/24h) indicates primary
aldosteronism

52. Primary Aldosteronism
Management
Referral to endocrinologist for
initial work-up, if Conn’s
suspected
Abdominal CT to localize
adenoma and r/o carcinoma
Adrenal vein sampling if CT is
negative

53. Primary Aldosteronism
Initial treatment
Unilateral Adenoma – laparoscopic surgical
excision
Bilateral hyperplasia (and pt who don’t want
surgery for adenoma)
Dietary sodium restriction
Spironolactone (aldosterone antag) 25mg Daily
Controls HTN and hypokalemia
Side effects in men – gynecomastia,
decreased libido, impotence
Eplerenone (less potent) 50-150mg TID with
minimal antiandrogen effects – better in
men

54. Primary Aldosteronism
Prognosis
Reverse HTN in 2/3 cases with treatment
Single adenoma
Able to stop medication after surgery
Will need to be monitored for life
Bilateral hyperplasia
Lifelong medication
Life-long monitoring of effectiveness and
side effects
Only 2% aldosterone secreting tumors are
malignant

55. Pheochromocytoma
• DEFINITION: catecholamine-producing tumor
derived from the sympathetic and parasympathetic
nervous system, usually located in the adrenal
gland
Pheo = Dusky Chromo = Color Cytoma = Cell
Tumor
The name refers to the color the tumor cells acquire
when stained with chromium salts

56. Pheochromocytoma
Well
vascularized
tumors that
arise from cells
derived from
paraglangia of
the
Sympathetic –
adrenal medulla
Parasympathetic

57. Pheochromocytoma
Epidemiology
Rare
Occurs in 2-8 out of 1 million persons/
yr
< 0.1% of hypertensive patients harbor
a pheochromocytoma
Mean age at diagnosis is 40 years
Can occur from early childhood until
late in life

58. Pheochromocytoma
Signs and symptoms
Variable clinical presentation and
known as the “great masquerader”
Classic triad
Episodes of headache, profuse
perspiration, and palpitations
Hypertension in is the dominant sign
May be sustained or episodic

59. Pheochromocytoma
Signs and symptoms
Paroxysms generally last <1 hour
During episodes of hormone
release patients are anxious,
pale and they experience
tachycardia and palpitations
May be precipitated by surgery,
positional changes, exercise,
pregnancy, urination and various
medications (TCAs, opiates)

60. Pheochromocytoma
Catecholamine crisis can lead to
Heart failure
Pulmonary edema
Arrhythmias
Intracranial hemorrhage

61. Pheochromocytoma
Differential Diagnosis
Essential hypertension
Panic attacks
Use of cocaine or amphetamines
Intracranial lesions
Thyrotoxicosis
Paroxysmal tachycardia

62. Pheochromocytoma
Diagnosis
Documentation of catecholamine excess
by biochemical testing and localization
of the tumor by imaging
Biochemical testing
These tumors store catecholamines,
which include epi, norepi and dopamine
High plasma and urine catecholamine and
metanephrine during or shortly after
attack

63. Pheochromocytoma
Biochemical testing (cont’d)
24 hour Urinary vanillylmandelic
acid (VMA) and catecholamines
Free plasma metanephrine
When values are increased 2-3 times the
upper limit of normal, a pheo is highly
likely
For borderline elevations – likely
false positive
Repeated testing may clarify the
diagnosis

64. Pheochromocytoma
Imaging Studies
Thin-section CT or MRI of adrenals
Sensitivity of ~90% for adrenal
pheochromocytoma
They are similar in sensitivity
If no adrenal tumor found, CT scan
extended to abdomen, pelvis, and
chest

65. Pheochromocytoma
Treatment
Surgical
Laparoscopic removal of tumor is the treatment of choice
HTN must be controlled prior to surgery
Preoperatively
Alpha-adrenergic blockader
Phenoxybenzamine, starting with a low dose and
increasing about every 3 days until hypertension is
controlled
Calcium channel blockers
Beta blockers
Can be added after alpha blockers and calcium channel
blockers if tachycardia persists

66. Pheochromocytoma
Malignant pheo
Term is generally restricted to tumors with
distant metastases
Most commonly found in lungs, bone or liver
Treatment options
Tumor mass reduction
Alpha blockers for symptoms
Chemotherapy
Nuclear medicine radiotherapy
5 year survival is 30-60%

67. Pheochromocytoma
Complications
Severe hypertension  end organ
damage
Catecholamine-induced cardiomyopathy
Sudden death from cardiac arrhythmia
Hypertensive crises with stroke

68. Pheochromocytoma
Prognosis
Complete cure usually achieved if
tumor successfully removed before
irreparable cardiovascular damage
In about 25%, hypertension persists or
returns in spite of successful surgery
Surgical mortality rate < 3%
Death may occur from hypertensive
crisis

69. Questions???

70. Questions???

71. Questions???

72. Questions???