cortisol/adrenal probs

• Cushing's disease


  Specifically pituitary adenoma (elevated ACTH secretion)
• Cushing's syndrome


  Excess corticosteroids from any cause, can be ACTH dependent or independent. Causes too much cortisol.
• Causes of Cushing's syndrome

  • Medications (ACTH independent only)
  • Bodily production (less common)
• Endogenous Cushing's syndrome

  Adrenal adenoma or ectopic ACTH hormone
• Adrenal insufficiency


  Autoimmune, infectious, metastatic cancer, lymphoma, medications
• Primary adrenal insufficiency


  Increased ACTH, decreased cortisol, decreased aldosterone
• Secondary adrenal insufficiency


  Decreased ACTH, decreased cortisol, regular aldosterone
• Autoimmune mediated destruction of adrenal cortex


  Addison's disease = primary adrenocortical insufficiency (chronic hypocortisolism), adrenal cortex is destroyed
• Clinical features of Cushing's disease/syndrome

  • Thin hair, red cheeks, acne, moon face, buffalo hump, supraclavicular fat pad, increased body/facial hair, weight gain, purple striae, pendulous abdomen, thin extremities with muscle atrophy, easy bruise, thin skin, slow wound healing
  • Menstrual irregularities, hirsutism, oily face, increased/decreased libido, virilization (due to inhibition of gonadotropin)
  • Fungal infections, hyperpigmentation
  • Glucose intolerance, progressive obesity, sleep apnea
  • Hypertension, increased risk, thromboembolic events, heart failure/dilated cardiomyopathy, proximal muscle weakness/wasting, bone loss
  • Depression, irritable, anxious, panic attacks, mild paranoia/mania
• Clinical features of Addison's disease

  • Crave salty foods, nausea/vomiting, orthostatic hypotension/hypotensive
  • Decreased cortisol -> decreased glucose in stress -> weakness/tiredness/disorientation
  • Overactive pituitary gland -> makes more melanocyte stimulating hormone (hyperpigmentation/bronzing of skin)
  • Low androgen levels (women) -> loss of armpit/pubic hair, decreased sex drive
  • Crisis symptoms: pain in back, abdomen, legs, vomiting, diarrhea, dehydration, hypotension -> death
• Managing Addisonian crisis

  1. Give sugar, steroids, salt

  2. Search for cause

  3. IV saline/5% dextrose (sugar/salt)

  4. IV hydrocortisone (steroids)
• Primary aldosteronism


  Excess sodium in blood makes water go intravascular so increased volume and hypertension, headache, facial flushing, loss of protons in kidney -> metabolic acidosis
• Expected lab values for Cushing's disease/syndrome

  • Increased glucose, increased triglycerides, increased WBC, glucosuria
  • Tests: salivary cortisol levels (2 nanograms/mL... get abnormal levels x2), 24 hr free cortisol level, dexamethasone suppression test
  • ACTH low in exogenous/adrenal tumor and high in Cushing's disease
  • Imaging: MRI of thorax, abdomen, pelvis (ectopic ACTH secretion), MRI of head (pituitary), CT abdomen (adrenals)
• Expected lab values for Addison's disease (primary adrenal gland)

  • Hyperkalemia, hypovolemia, hyponatremia, high H (metabolic acidosis), low serum cortisol, high ACTH, low cortisol
• Expected lab values for adrenal insufficiency

  • ACTH AM levels high, high potassium/renin, low glucose/sodium, cortisol AM levels low (<3mg/dL at 8am is diagnosis)
  • Secondary: CRH stim test, low ACTH, low cortisol
• Cushing's syndrome occurs when there is excess production or use of cortisol in the body, leading to symptoms such as weight gain, fatigue, and muscle weakness.
• Addison's disease results from decreased production of adrenal hormones, causing symptoms like fatigue, low blood pressure, and darkening of skin color.
• The pituitary gland secretes antidiuretic hormone (ADH) which helps maintain water balance in the body.
• Likely etiologies of SIADH

  • Post-op pts due to admin of hypotonic fluids
  • Drugs
  • Body's response to stress
  • CNS prob (trauma, stroke, hemorrhage, infection, mental illness)
  • Ectopic ADH production (SCLC, pneumonia, TB, CF)
  • Meds
  • Injury/surgical removal of pituitary
  • Acute psychosis
  • HIV infection
• Signs and symptoms of SIADH

  • Due to hyponatremia/dec ECF osmolality: malaise, N/V, weak, tired, dizzy, confused, lethargic, anorexia, muscle cramps, myoclonus, tremors, seizures
  • Rapid fall in Na→ delirium, confusion, seizures
• Laboratory findings for SIADH

  • Serum sodium less than 135 mEq/L
  • Serum osmolality less than 275 mOsm/kg
  • Urine sodium greater than 40 mEq/L
  • Urine osmolality greater than 100 mOsm/kg
  • Absence of clinical evidence of volume depletion– normal skin turgor, normal BP
  • Absence of other causes of hyponatremia
  • Correction of hyponatremia by fluid restriction
• Alarm symptoms associated with SIADH

  • Delirium
  • Confusion
  • Seizures
• First line treatment for mild/moderate SIADH

  1. Restrict water to <800 mL/day

  2. NaCl tablets/IV saline or loop diuretics (furosemide)
• First line treatment for severe SIADH

  1. 100 mL bolus of 3% hypertonic saline given in the first 3-4hrs

  2. Severe Persistent- Vasopressin receptor antagonists - Conivaptan (IV) or tolvaptan (oral)
• Hyperaldosteronism


  Tied to RAAs, producing above normal levels of aldosterone, impacts CV in HTN/resistant HTN
• Hyperaldosteronism effects


  1. Inc Na absorption in collecting tubule

  2. Inc water

  3. Hypokalemia causes constipation, wake, arrhythmias

  4. Hypernatremia
• Hyperaldosteronism signs/symptoms


  • HTN, HA, facial flushing, metabolic alkalosis (due to loss of protons in the kidneys)
• Primary hyperaldosteronism


  Adrenal gland problem, Na high, K low, pH high, high aldosterone, low renin
• Secondary hyperaldosteronism


  Hypersecretion due to something in body, HIGH ALDOSTERONE AND RENIN
• Causes of secondary hyperaldosteronism

  • Renal artery stenosis
  • DI aka arginine vasopressin disorders
• Nephrogenic diabetes insipidus


  Deficiency/resistance to ADH, pts on lithium are at a huge risk
• Nephrogenic diabetes insipidus effects

  1. Dec ability to abs water

  2. High polyuria/dipsia

  3. Dec urine osmolality

  4. Inc plasma osmolality
• Types of diabetes insipidus

  • Central- problem w secretion of ADH from post pituitary
  • Nephrogenic- kidneys not responding appropriately to ADH
• Central diabetes insipidus signs/symptoms

  • Polyuria, polydipsia, nocturia, occasional hypovolemia
• Central diabetes insipidus lab findings

  • High serum osmolality, low urine osmolality, high Na, norm glucose
• Central diabetes insipidus workup


  Serum electrolytes, urine SG, plasma ADH levels, water deprivation, desmopressin (ADH) stim test, MRI to r/o pituitary adenoma
• Central diabetes insipidus treatment


  Desmopressin DDAVP, AA sub of ADH
• Nephrogenic diabetes insipidus treatment


  Diuretics, DDAVP, thiazide diuretics
• Pheochromocytoma


  Catecholamine secreting tumor from chromaffin cells in adrenal medulla, can excrete norepi/epi
• Pheochromocytoma signs/symptoms


  • 5P's (paroxysmal, pain/HA, pressure/HTN, palpitations, perspirations), Classic triad: episodic HA, night sweats, tachycardia