Review of Adrenal Excess and Adrenal Deficiency

00:00 Let's talk about adrenal glands.

00:04 We're going to review adrenal excess and adrenal deficiency.

00:08 Starting with adrenal excess, these manifest as excesses of cortisol in Cushing syndrome, excesses of adrenaline in pheochromocytoma, and increased aldosterone in the condition known as primary aldosteronism.

00:22 Deficiency states primarily involve all three hormones as well as androgens.

00:27 This condition is known as Addison's disease.

00:31 Cushing syndrome may present with a low or normal ACTH with an elevated cortisol.

00:37 Causes may be iatrogenic in cases of exogenous steroid use.

00:42 This usually is where a prednisone equivalent of greater than 10-20 milligrams per day are used.

00:48 This can be administered either orally, intravenously, intramuscularly, subcutaneously, or intraarticularly and may even be in the form of creams used in the treatment of chronic dermatological conditions.

01:04 Endogenous causes include ACTH dependent and ACTH independent.

01:11 ACTH dependent Cushing syndrome is caused by ACTH-secreting pituitary adenomas or ACTH-secreting carcinomas.

01:21 ACTH independent causes include adrenal adenomas and adrenal carcinomas.

01:28 Let's go through an algorithm to confirm the diagnosis of Cushing syndrome.

01:33 When you clinically suspect Cushing syndrome, the first step is to exclude exogenous glucocorticoids.

01:39 Once that's done, we move on to initial testing.

01:43 These tests could include a 24-hour urinary free cortisol test, a late-night salivary cortisol test, and a 1 milligram dexamethasone suppression test.

01:56 Of these three tests, the first two, the 24-hour urine free cortisol and the late-night salary cortisol tests needed to be repeated if they're positive to confirm the diagnosis.

02:09 Moving down the algorithm, if these tests are normal, Cushing syndrome is unlikely.

02:14 On the left side of the algorithm, if these tests are abnormal, the next step is to exclude physiologic hypercortisolism.

02:23 What is physiological hypercortisolism? That's essentially increases in cortisol that are caused by psychological stress or severe illness and can certainly muddy the picture in the diagnosis of Cushing syndrome.

02:37 But once you have excluded those entities, you then move down to additional testing which can include imaging.

02:44 If the imaging is positive, you've confirmed your diagnosis of Cushing syndrome.

02:49 If however it's normal, repeating the initial test to confirm that they were indeed positive is probably the next step.

02:57 If these are normal, then crushing syndrome is unlikely.

03:01 The treatment of Cushing syndrome consists of the surgical removal of the adrenal gland or the pituitary mass or the ectopic tumor that is producing ACTH.

03:10 Bisphosphonates for low bone density are a good idea because long-term cortisol would have invariably led to osteoporosis.