Adrenal Function, Adrenal

hyperfunction and hypofunction

 NORMAL PHYSIOLOGY
• In normal subjects, Coritoctropin releasing hormone (CRH)
released from the hypothalamus is carried to the anterior
pituitary gland, where it stimulates the synthesis and release
of ACTH and other proopiomelanocortin (POMC)-derived
peptides.
• The ensuing increase in plasma ACTH concentrations
stimulates adrenal cortisol secretion, which in turn inhibits
hypothalamic CRH synthesis and secretion and inhibits the
synthesis of POMC and the release of ACTH and other POMC
peptides from the anterior pituitary.
Adrenocortico-hypothamo-pituitary axis
 NORMAL PHYSIOLOGY
• ACTH secretion is pulsatile; while the pulse frequency remains
constant, the amplitude of the pulses varies in a circadian
fashion.
• ACTH secretion rates and plasma ACTH concentrations are
highest at about the time of awakening in the morning and
lowest in the late evening and very early morning hours.
• However, various stressful stimuli increase ACTH secretion
and, as a consequence, cortisol secretion.
 Basic Physiology - Adrenal steroid
biosynthesis
• The major adrenal steroid hormones are synthesized in
different areas of the adrenal cortex:
• Glucocorticoids (particularly cortisol), androgens, and
estrogens in the zona fasciculata and reticularis
• Aldosterone in the zona glomerulosa.
• Cholesterol is the substrate for the synthesis of all steroid
hormones.
 NORMAL PHYSIOLOGY
• Cortisol metabolism
• Cortisol exists in two forms in serum: some is free (unbound) but
most is bound to corticosteroid-binding globulin (CBG).
• The free cortisol in serum is filtered into the saliva and urine or
enters tissue for action and metabolism (mostly in the liver and
kidneys).
• Its hepatic and renal metabolites are excreted in the urine as 17-
hydroxycorticosteroids (17-OHCS) or 17-ketogenic steroids (17-
KGS), and some of its precursors are excreted in the form of 17-
ketosteroids (17-KS).
• Cortisol secretion normally reflects that of ACTH, and is therefore
also pulsatile.
 Metabolism of adrenal steroids
• The major site of cortisol metabolism is believed to be the
liver.
• There, cortisol is reduced or oxidized and hydroxylated, and
the products of these reactions are made water soluble by
conjugation with sulfate or glucuronic acid in preparation for
their excretion in urine.
PRINCIPLES

LABORATORY EVALUATION OF
PITUITARY FUNCTION
Basic principles in the laboratory evaluation
of adrenocortical function

• Evaluation of adrenal function requires measurement of

the relevant adrenal hormones and their metabolites and
sometimes of the secretagogues that regulate their
secretion.
• Circulating hormone levels may have a diurnal rhythm. And
test strategies should be planned with this in mind.
Basic principles in the laboratory evaluation
of adrenocortical function

• In addition, other tests that evaluate the function of

systems that are regulated by nonhormonal factors may
not have broadly applicable "normal" values. E.g. The
RAAS is regulated in part by the effective blood volume,
which is determined in normal subjects by sodium intake.
Thus, interpretation of measurements of plasma renin
activity and serum aldosterone requires knowledge of the
level of sodium intake which, in the steady state, can be
estimated from 24-hour urinary sodium excretion.
Basic principles in the laboratory evaluation
of adrenocortical function

• LABORATORY AND PATIENT ERRORS

• Serum cortisol concentration are dependent on CBG
concentrations.
• Low CBG concentrations, as may be seen in critical illness
or nephrotic syndrome result in a lower than expected
cortisol value.
• Conversely, high CBG concentrations as seen with oral
estrogen administration, increase serum cortisol
concentrations
Basic principles in the laboratory evaluation
of adrenocortical function
• The major sources of patient errors:
– Failure to inform the physician of other medications
that may interfere with the diagnostic tests, the
hormonal assays, or both.
– Failure to collect 24-hour urine specimens properly.
 Measurement of ACTH

• Measurements of plasma ACTH are extremely useful in

the diagnosis of both Cushing's syndrome and adrenal
insufficiency.
• Normal plasma values are between 20 and 80 pg/mL
(4.5 and 18 pmol/L) at 8 AM.
• The values fall during the waking hours and are usually
less than 20 pg/mL (4.5 pmol/L) at 4 PM and less than 5
pg/mL (1.1 pmol/L), within one hour after the usual time
of falling sleep.
 Measurement of ACTH
• Early morning (6 to 8 AM) plasma ACTH is high and serum
cortisol is low in primary adrenal insufficiency.
• Both plasma ACTH and serum cortisol values are low in
hypothalamic CRH deficiency or pituitary ACTH deficiency.
• In Cushing's syndrome, plasma ACTH and serum cortisol
concentrations are measured in the late evening, the time at
which the concentrations are usually lowest in normal
persons. Loss of the normal circadian rhythm in secretion
occurs in Cushing's syndrome
• In patients with Cushing's syndrome due to primary
adrenocortical disorders , plasma ACTH concentrations are
low, often undetectable, but serum cortisol concentrations are
high.
 Measurement of ACTH
• Several factors may influence plasma ACTH assay results:
• ACTH is unstable in blood at room temperature, is cleaved by
enzymes in blood cells and platelets, and adheres to glass and
some plastic surfaces therefore, how blood is collected and
plasma is prepared and stored may markedly affect the
measured ACTH concentration
• Normal subjects and patients with adrenal disorders may
respond rapidly to stress with increased ACTH secretion. For
this reason, blood samples should be obtained with
indwelling needles or catheters.
 Measurement of ACTH
Patients with major depressive disorder, may have high
plasma ACTH concentrations
One must be certain that the patient is not taking, or has
not recently taken, glucocorticoids, which can suppress
hypothalamic-pituitary-adrenal function.
 MEASUREMENT OF CRH 
• Peripheral plasma CRH increase during pregnancy from about
due to placental production. This results in increased maternal
plasma ACTH and serum cortisol concentrations, and urinary
and salivary cortisol. But there is no evidence of altered
hypothalamic-pituitary-adrenal axis function in pregnancy.
• Plasma CRH concentrations are also high in the ectopic CRH
syndrome.
 Measurement of cortisol
• Normal values
• The serum cortisol concentration normally reflects that of ACTH
and therefore has circadian rhythmicity
• In normal subjects serum cortisol concentrations are higher in
the early morning (about 6 AM) and are lowest one hour after
the usual time of sleep.
• Cortisol secretion is episodic. A single serum value, if it falls
within the normal range, is inconclusive therefore stimulation or
suppression testing should be performed when there is doubt.
• Nevertheless, samples drawn at the appropriate time can be
very helpful in excluding adrenal hypofunction or hyperfunction.
 Measurement of cortisol
• Patients with primary or secondary adrenal insufficiency have
low early morning serum cortisol concentrations.
• Most patients with Cushing's syndrome have serum cortisol
concentrations one hour after sleep being high ie, they have
an abnormal or absent circadian rhythm
• Recent hydrocortisone (cortisol) or cortisone administration
may result in high serum cortisol concentrations.
 Measurement of urinary excretion of
endogenous and exogenous glucocorticoids
• Urinary cortisol excretion results from glomerular filtration of
serum free cortisol and is therefore an index of the integrated
24-hour serum free cortisol concentration.
• Urinary 17-OHCS excretion is increased in patients with
Cushing's syndrome and decreased in patients with adrenal
insufficiency.
• The validity of the results is critically dependent upon normal
renal function. Individuals with renal impairment have
progressively less cortisol excretion.
• Over- or under-collection of the 24-hour specimen can bias
the results. Because of this, measurement of cortisol
excretion must include concurrent measurement of creatinine
excretion.
CUSHING’S SYNDROME

ADRENAL EXCESS
 Introduction
Cushing’s Syndrome results from chronic exposure to excessive
levels of glucocorticoids.
Although the condition is considered rare, the clinical spectrum
of the disease is broad, and its investigation is frequently
required given the high prevalence of many of its non-specific
symptoms such as obesity, muscle weakness and depression.
In its severe form and when untreated, the metabolic upset of
Cushing's syndrome is associated with a high mortality but
more subtle excesses of cortisol may have significant effects on
glycaemic control and blood pressure, and may therefore be an
important cause of morbidity.
 Pathophysiology & Aetiology
• The glucocorticoid cortisol is secreted from the zona
fasciculata and reticularis of the adrenal gland under the
stimulus of adrenocorticotropin (ACTH) from the pituitary
gland.
• ACTH in turn is secreted in response to corticotropin releasing
hormone (CRH) and vasopressin from the hypothalamus. 
 Pathophysiology & Aetiology
• Cortisol exerts negative feedback control on both CRH and
vasopressin in the hypothalamus, and ACTH in the pituitary. In
normal individuals, cortisol is secreted in a circadian rhythm;
levels fall during the day from a peak at 07.00h-08.00h to a
nadir at around midnight: they then begin to rise again at
02.00h.
• It is the loss of this circadian rhythm, together with loss of the
normal feedback mechanism of the hypothalamo-pituitary-
adrenal  (HPA) axis, which results in chronic exposure to
excessive circulating cortisol levels and that gives rise to the
clinical state of endogenous Cushing's syndrome.
 Causes of Cushing's syndrome
• Cushing's syndrome may be either ACTH -dependent or –
independent.
•  The causes of ACTH-dependent Cushing's syndrome are:
• Cushing's disease (pituitary hypersecretion of ACTH)
• Ectopic secretion of ACTH by nonpituitary tumors
• Ectopic secretion of corticotropin-releasing hormone (CRH)
by nonhypothalamic tumors causing pituitary
hypersecretion of ACTH
• Iatrogenic or factitious Cushing's syndrome due to
administration of exogenous ACTH
 Causes of Cushing's syndrome
The causes of ACTH-independent Cushing's syndrome are:
◦ Iatrogenic or factitious Cushing's syndrome (commonest
cause) caused by the exogenous administration of
glucocorticoids.
◦ Adrenocortical adenomas and carcinomas .
◦ Primary pigmented nodular adrenocortical disease, also
called bilateral adrenal micronodular hyperplasia.
◦ Bilateral ACTH-independent macronodular hyperplasia,
this disorder must be distinguished from macronodular
hyperplasia in Cushing's disease in which plasma ACTH
concentrations are not suppressed .
 Causes of Cushing's syndrome
• Pseudo-Cushing's states are conditions in which a patient
presents with clinical features suggestive of true Cushing's
syndrome with some biochemical evidence of
hypercortisolaemia. E.g. Depression, alcohol abuse and
certain types of simple obesity.
 Cushing's disease
• Caused by pituitary adenoma or by corticotroph hyperplasia.
• Mainly microadenomas; only 5% are macroadenomas.
• The amplitude and duration, but not the frequency, of ACTH
secretory episodes are increased in Cushing's disease, and the
normal ACTH circadian rhythm is usually lost.
• There is loss of tight synchrony between ACTH and cortisol
secretory dynamics, because ACTH secretion by the adenoma
is not subject to hypothalamic regulation and is relatively
resistant to direct glucocorticoid inhibition.
 Cushing's disease
• The increased plasma ACTH concentrations, acting alone or in
concert with other growth factors, cause bilateral
adrenocortical hyperplasia and hypersecretion of cortisol.
• Consequently, the normal circadian rhythm in cortisol
secretion is also lost.
• The increased cortisol secretion is reflected by increased
urinary excretion of cortisol and 17-OHCS. ACTH secretion is
increased more than that of cortisol, suggesting that the
adrenal cortex is relatively unresponsive to excess ACTH.
 Cushing's disease
• The relative activity of the enzymes involved in cortisol
biosynthesis does not change, and therefore the production
and excretion of cortisol precursors are increased
proportionately.
• The chronic hypercortisolemia inhibits hypothalamic CRH
secretion and also inhibits ACTH secretion by the normal,
nonadenomatous pituitary corticotrophs, which atrophy.
 Cushing's disease
The corticotroph adenoma cells are relatively resistant to
negative feedback inhibition by glucocorticoids.
Hence it permits the use of dexamethasone suppression to
distinguish between pituitary and ectopic ACTH secretion; the
latter is usually very resistant to glucocorticoid negative
feedback.
 Ectopic ACTH syndrome
• Non-pituitary tumor secretion of ACTH causes bilateral
adrenocortical hyperplasia and hyperfunction.
• The increased serum cortisol concentrations inhibit
hypothalamic CRH secretion and block CRH stimulation of the
pituitary corticotrophs, suppressing pituitary ACTH release.
• Tumor ACTH secretion is not inhibited by cortisol or other
glucocorticoids.
 Ectopic ACTH syndrome
In general, tumors causing the ectopic ACTH syndrome tend
to secrete a disproportionately greater proportion of POMC
precursors, and these may be their major product.
Tumors of a wide variety of tissues, usually carcinomas rather
than sarcomas or lymphomas, have been associated with the
ectopic ACTH syndrome. Including lung, pancreas, or thymus.
These usually arise from neuroendocrine cells in those
tissues.
 Ectopic CRH syndrome
•  In the ectopic CRH syndrome, CRH secretion by the tumor
causes hyperplasia and hypersecretion of the pituitary
corticotrophs, resulting sequentially in ACTH hypersecretion,
cortisol hypersecretion, and bilateral adrenal hyperplasia.
ACTH-INDEPENDENT CUSHING'S SYNDROME

• Primary adrenocortical hyperfunction

• In Cushing's syndrome due to primary adrenocortical disease
increased cortisol secretion suppresses both CRH and ACTH
secretion, as it does in normal subjects.
• The normal pituitary corticotrophs atrophy, as do the normal
zonae fasciculata and reticularis of the adrenal glands.
Iatrogenic or factitious Cushing's syndrome 

• Caused by administration of excessive amounts of a synthetic

glucocorticoid, and only rarely by ACTH administration
• Occasionally it can be caused by the administration of
megestrol acetate, which has some intrinsic glucocorticoid
activity. Exogenous glucocorticoids inhibit CRH and ACTH
secretion, causing bilateral adrenocortical atrophy.
• Plasma ACTH, serum and salivary cortisol concentrations, and
urinary 17-OHCS and cortisol excretion (unless cortisol is the
steroid administered) are all low.
 Investigation of Cushing's syndrome
 After the diagnosis of hypercortisolism is established, its cause
must be determined.
 The first step in the evaluation is to determine whether the
hypercortisolism is ACTH-dependent (ie, due to a pituitary or
nonpituitary ACTH-secreting tumor), or ACTH-independent
(ie, due to an adrenal source) by measuring plasma ACTH.
 A low plasma ACTH concentration in a hypercortisolemic
patient is evidence of ACTH-independent disease; imaging of
the adrenal glands is usually the next diagnostic procedure in
these patients.
 One can assume that cortisol secretion is ACTH-dependent (ie,
due to pituitary disease or ectopic ACTH or CRH secretion) if
the plasma ACTH concentration is high.
 Investigation of Cushing's syndrome
• Plasma ACTH values between 5 and 20 pg/mL (1.1 to 4.4
pmol/L) are less definitive, but usually indicate that cortisol
secretion is ACTH-dependent. For these patients, a CRH
stimulation test may be helpful.
 Investigation - ACTH-DEPENDENT
CUSHING'S SYNDROME

• In patients with ACTH-dependent Cushing's syndrome, the

final stage of the diagnostic evaluation is to determine the
source of ACTH secretion
• The great majority of these patients have a pituitary
corticotroph adenoma (Cushing's disease) rather than
ectopic ACTH secretion. Ectopic CRH secretion may very
rarely cause Cushing's syndrome.
 Investigation - ACTH-DEPENDENT
CUSHING'S SYNDROME

 Patients with ACTH-dependent disease should undergo a

high-dose dexamethasone suppression test and CRH
stimulation test.
 Suppression of cortisol during dexamethasone
administration and increases in plasma ACTH and serum
cortisol after CRH administration are consistent with the
diagnosis of a pituitary adenoma (Cushing's disease).
High-dose dexamethasone suppression tests

• Overnight 8 mg test —  Dexamethasone (8 mg) is taken orally

between 11 PM and midnight, and a single blood sample is
drawn at 8 AM the next day for measurement of serum
cortisol
• With this protocol, the 8 AM serum cortisol concentration is
less than 5 µg/dL (140 nmol/L) in most patients with Cushing's
disease (ie, a pituitary tumor), and is usually undetectable in
normals.
High-dose dexamethasone suppression tests

• Standard two-day, 8 mg test

• The patient collects a baseline 24-hour urine specimen after
which the patient begins taking 2 mg of dexamethasone
orally every six hours for a total of eight doses, usually at 8
AM, 2 PM, 8 PM, and 2 AM, and the urine collections are
continued.
• The urine collections are assayed for urinary free cortisol, and
creatinine.
• In addition, a blood specimen can be collected six hours after
the last dose of dexamethasone for measurement of cortisol,
dexamethasone, and ACTH.
High-dose dexamethasone suppression tests

• Urinary free cortisol excretion is less than 5 µg (14 nmol) per

24 hours. Serum cortisol and plasma ACTH concentrations are
low and usually undetectable in normal subjects.
• Most patients with Cushing's disease demonstrate a
significant (ie, greater than day-to-day baseline variation)
reduction in urinary cortisol excretion.
• The vast majority of patients with the ectopic ACTH syndrome
from malignant tumors fail to suppress with high-dose
dexamethasone.
 Investigation of Cushing's syndrome
• CRH stimulation test
• Most patients with Cushing's disease respond with ACTH and
cortisol increases within 45 minutes after the intravenous
administration of corticotropin-releasing hormone (CRH)
• Thus, a response to CRH should differentiate Cushing's disease
from all other causes of Cushing's syndrome.
 Investigation of Cushing's syndrome
 Petrosal venous sinus catheterization — The most direct way
to demonstrate pituitary ACTH hypersecretion is to document
a central-to-peripheral ACTH gradient in the blood draining
the tumor. The petrosal venous sinus drains the pituitary via
the cavernous sinus
 To perform this procedure, catheters are inserted via the
jugular or femoral veins into both inferior petrosal veins.
 ACTH is measured in petrosal and peripheral venous plasma
before and within 10 minutes after administration of CRH.
 Interpretation — A central-to-peripheral plasma ACTH
gradient of ≥ 2.0 before CRH administration, or ≥ 3.0 after
CRH, is diagnostic of a pituitary source of ACTH.
 Investigation of Cushing's syndrome
• False negatives — False negative results likely result from
poor catheter placement or anomalous or asymmetric venous
drainage.
• False positives — False positive results occur rarely in patients
with ectopic ACTH syndrome or an adrenal tumor. Presumably
pituitary ACTH secretion is incompletely suppressed in these
patients
 Investigation of Cushing's syndrome
• Complications 
• Cerebrovascular accident
• Pulmonary embolism and deep venous thrombosis
• Inguinal or jugular hematomas
• Imaging studies
• The diagnosis of Cushing's syndrome and its cause lie entirely
in the domain of the endocrine laboratory.
• Imaging procedures provide no information about function
and are useful only for tumor localization.
ADDISON’S DISEASE

ADRENAL INSUFFICIENCY
 Adrenal Insufficiency
• Adrenal insufficiency can be classified as primary or
secondary.
• Primary adrenal insufficiency occurs when the adrenal gland
itself is dysfunctional.
• Secondary adrenal insufficiency, also called central adrenal
insufficiency, occurs when a lack of secretion of corticotropin-
releasing hormone (CRH) from the hypothalamus or of
adrenocorticotropic hormone (ACTH) from the pituitary leads
to hypofunction of the adrenal cortex.
• Adrenal insufficiency can further be classified as congenital or
acquired.
 Adrenal Insufficiency - Causes
• Central adrenal insufficiency
– Iatrogenic, caused by long-term administration of
glucocorticoids.
– Recent treatment with megestrol acetate, an orexigenic
agent, has also resulted in iatrogenic adrenal suppression.
 Adrenal Insufficiency - Causes
• Acquired primary adrenal insufficiency
– Autoimmune destruction of the adrenal cortex. This
disorder may occur in isolation or may be part of a
polyglandular autoimmune disorder.
– Other causes of central adrenal insufficiency include
congenital or acquired hypopituitarism and ACTH
unresponsiveness.
 Adrenal Insufficiency
• Relatively uncommon causes of adrenal failure include the
following:
• Adrenal hemorrhage
• Infections (eg, TB, HIV infection)
• Neoplastic destruction
• Metabolic disorders
• Administration of the anesthetic agent etomidate
 Adrenal Insufficiency
– Hemochromatosis may cause either primary or secondary
adrenal insufficiency.
• Congenital primary adrenal insufficiency
– Congenital disease may occur as a result of adrenal
hypoplasia or hyperplasia.
• Relative adrenal insufficiency
– The term relative adrenal insufficiency has been coined to
describe patients with critical illness who do not appear to
mount the cortisol response expected given the severity of
their illness. 
 Causes of primary adrenal insufficiency
(Addison's disease)
• AUTOIMMUNE ADRENALITIS
• The result of an autoimmune process that destroys the
adrenal cortex. There is evidence of both humoral and cell-
mediated immune mechanisms directed at the adrenal
cortex, often associated with autoimmune destruction of
other endocrine glands.
• Approximately one-half of patients with autoimmune adrenal
insufficiency have one or more other autoimmune endocrine
disorders
 Causes of primary adrenal insufficiency
(Addison's disease)
• INFECTIOUS ADRENALITIS
• A variety of infectious agents can infect the adrenal gland and
lead to adrenal insufficiency.
– Tuberculosis
– Disseminated fungal infections
– HIV infection
– Other infections
 Causes of primary adrenal insufficiency
(Addison's disease)
• HEMORRHAGIC INFARCTION 
•  Acute adrenal insufficiency may occur as a result of bilateral
adrenal infarction caused by hemorrhage or adrenal vein
thrombosis. Adrenal hemorrhage has been associated with
meningococcemia (Waterhouse-Friderichsen syndrome)
• Major risk factors for adrenal hemorrhage include
anticoagulant drug or heparin therapy or coagulopathy,
thromboembolic disease, hypercoagulable states such as
antiphospholipid syndrome, physical trauma, the
postoperative state, sepsis, and any cause of severe stress .
 Causes of primary adrenal insufficiency
(Addison's disease)
• METASTATIC DISEASE
• Infiltration of the adrenal glands by metastatic cancer is
common, probably because of their rich sinusoidal blood
supply.
 Causes of primary adrenal insufficiency
(Addison's disease)
• DRUGS
• Drugs which inhibit cortisol biosynthesis e.g. etomidate,
ketoconazole
• Drugs which accelerate the metabolism of cortisol and most
synthetic glucocorticoids by inducing hepatic mixed-function
oxygenase enzymes - phenytoin, barbiturates , and rifampin.
• The adrenocorticolytic drug mitotane is used to treat adrenal
tumors and to diminish cortisol synthesis in refractory
Cushing's syndrome.
 Causes of primary adrenal insufficiency
(Addison's disease)
• SEVERE INFLAMMATORY DISEASE
• Seriously ill patients may have lower serum cortisol
concentrations during severe inflammatory disease than
when there is less inflammation.
 Causes of primary adrenal insufficiency
(Addison's disease)
• CONGENITAL ADRENAL HYPOPLASIA
• Congenital adrenal hypoplasia, a condition in which the
adrenal cortex does not develop normally.
 Causes of secondary and tertiary adrenal
insufficiency
• Adrenal insufficiency caused by interference with
corticotrophin (ACTH) secretion by the pituitary gland
(secondary), or interference with corticotropin-releasing
hormone (CRH) secretion by the hypothalamus (tertiary).
• The ACTH deficiency may be isolated, or occur in conjunction
with other pituitary hormone deficiencies
(panhypopituitarism).
 Causes of secondary and tertiary adrenal
insufficiency
• Panhypopituitarism
• Pituitary tissue can be destroyed and hormone secretion
reduced by large pituitary tumors or craniopharyngiomas,
infectious diseases such as tuberculosis or histoplasmosis,
infiltrative diseases, lymphocytic hypophysitis, head trauma,
and large intracranial artery aneurysms.
• Pituitary infarction can occur at the time of delivery if
excessive blood is lost and hypotension occurs (Sheehan's
syndrome),
 Causes of secondary and tertiary adrenal
insufficiency
• Hemorrhage may occur into a pituitary tumor (pituitary
apoplexy).
• Pituitary metastases are frequently (about 5 percent) found in
patients with disseminated cancer at autopsy; however, these
metastases rarely reduce hormone secretion.
• ACTH deficiency due to genetic pituitary abnormalities is rare.
ACTH and cortisol deficiency have been described in patients
with multiple pituitary hormone deficiencies due to mutations
in the PROP-1 (Prophet of Pit-1) gene.
 Causes of secondary and tertiary adrenal
insufficiency
• Isolated ACTH deficiency 
• Isolated ACTH deficiency is a rare disorder. The defect is
probably at the pituitary level because there is no ACTH
secretory response to CRH or vasopressin, as there usually is
in hypothalamic disorders
 Causes of secondary and tertiary adrenal
insufficiency
• Megestrol acetate
• It is a progestin with some glucocorticoid activity; thus, its
withdrawal can occasionally cause secondary adrenal
insufficiency
• Opiates — Acute administration of cocaine increases ACTH
and cortisol similar to other stressors.
 Causes of secondary and tertiary adrenal
insufficiency
• TERTIARY ADRENAL INSUFFICIENCY
• Chronic high-dose glucocorticoid therapy — Suppression of
hypothalamic-pituitary-adrenal function by chronic
administration of high doses of glucocorticoids.
• After the cure of Cushing's syndrome — Tertiary adrenal
insufficiency also occurs in patients who are cured of Cushing's
syndrome by removal of a pituitary or nonpituitary ACTH-
secreting or a cortisol-secreting adrenal tumor.
• Other causes — Any process that involves the hypothalamus
and interferes with CRH secretion will result in tertiary adrenal
insufficiency. Such processes include tumors, infiltrative
diseases such as sarcoidosis, and cranial radiation.
 Clinical manifestations of adrenal
insufficiency
• Depend upon the rate and extent of loss of adrenal function,
whether mineralocorticoid production is preserved, and the
degree of stress.
• The onset of adrenal insufficiency is often very gradual and it
may go undetected until an illness or other stress precipitates
adrenal crisis.
 Clinical manifestations of adrenal
insufficiency
• ADRENAL CRISIS — may occur in the following situations:
• In a previously undiagnosed patient with primary adrenal
insufficiency who has been subjected to serious infection or
other acute, major stress.
• In a patient with known primary adrenal insufficiency who
does not take more glucocorticoid during an infection or other
major illness, or has persistent vomiting caused by viral
gastroenteritis or other gastrointestinal disorders.
 Clinical manifestations of adrenal
insufficiency
• After bilateral adrenal infarction or bilateral adrenal
hemorrhage.
• Less frequently in patients with secondary or tertiary adrenal
insufficiency during acute stress, but is sometimes seen with
acute cortisol deficiency due to pituitary infarction.
• In patients who are abruptly withdrawn from doses of
glucocorticoid that cause secondary adrenal insufficiency.
Importantly, this includes not only oral but inhaled
medications.
 Clinical manifestations of adrenal
insufficiency
• The predominant manifestation of adrenal crisis is shock, but
the patients often have nonspecific symptoms such as
anorexia, nausea, vomiting, abdominal pain, weakness,
fatigue, lethargy, fever, confusion or coma.
• The major hormonal factor precipitating adrenal crisis is
mineralocorticoid, not glucocorticoid, deficiency, and the
major clinical problem is hypotension.
 Clinical manifestations of adrenal
insufficiency
• CHRONIC PRIMARY ADRENAL INSUFFICIENCY
• Patients with chronic primary adrenal insufficiency may have
symptoms and signs of glucocorticoid, mineralocorticoid, and
in women, androgen deficiency.
• In contrast, patients with secondary or tertiary adrenal
insufficiency usually have normal mineralocorticoid function.
 Clinical manifestations of adrenal
insufficiency
• Common features
• Chronic malaise
• Lassitude
• Fatigue that is worsened by exertion and improved with bed
rest
• Weakness that is generalized, not limited to particular muscle
groups
• Anorexia
• Weight loss
 Clinical manifestations of adrenal
insufficiency
• Gastrointestinal complaints — nausea, occasionally vomiting,
abdominal pain, or diarrhea that may alternate with
constipation.
• Hypotension — Cardiovascular symptoms include postural
dizziness or syncope.
• Electrolyte abnormalities — Hyponatremia is found in 85 to
90 percent of patients, reflecting both sodium loss and
volume depletion.
• Salt craving, sometimes with massive salt ingestion, is a
distinctive feature in some patients.
 Clinical manifestations of adrenal
insufficiency
Hyperkalemia often associated with a mild hyperchloremic
acidosis occurs in 60 to 65 percent of patients due to
mineralocorticoid deficiency.
Hypoglycemia — Hypoglycemia may occur after prolonged
fasting or, rarely, several hours after a high-carbohydrate meal.
Hyperpigmentation — Hyperpigmentation, which is evident in
nearly all patients with primary adrenal insufficiency, is the
most characteristic physical finding
Sexual dysfunction — Decreased axillary and pubic hair and
loss of libido are common in women, in whom androgen
production primarily occurs in the adrenal glands
 Clinical manifestations of adrenal
insufficiency
Musculoskeletal symptoms — Diffuse myalgia and arthralgia
are frequent symptoms in patients with adrenal insufficiency.
Auricular-cartilage calcification — Calcification of the auricular
cartilages may occur in long-standing primary or secondary
adrenal insufficiency.
Psychiatric manifestations — Many patients with severe or
long-standing adrenal insufficiency have psychiatric symptoms,
Vitiligo — Patchy, often bilaterally symmetrical areas of
depigmented skin (vitiligo), the result of autoimmune
destruction of dermal melanocytes, occur on the trunk or
extremities in 10 to 20 percent of patients with autoimmune
adrenal insufficiency
Laboratory Diagnosis of adrenal insufficiency

• Confirmation of the clinical diagnosis of adrenal insufficiency

is a three stage process:
– Demonstrating inappropriately low cortisol secretion
– Determining whether the cortisol deficiency is dependent
on or independent of ACTH deficiency and evaluating
mineralocorticoid secretion in patients without ACTH
deficiency
– Seeking a treatable cause of the primary disorder.
Laboratory Diagnosis of adrenal insufficiency

• Subnormal cortisol secretion

• The diagnosis of adrenal insufficiency of any cause depends
entirely upon the demonstration of inappropriately low
cortisol production.
• In normal subjects serum cortisol concentrations are higher in
the early morning than at other times of the day. Therefore,
an early morning low serum cortisol concentration provides
clear evidence that the patient has adrenal insufficiency.
• Serum cortisol measurements taken at other times are of no
value in establishing the diagnosis of adrenal insufficiency.
Laboratory Diagnosis of adrenal insufficiency
Subnormal response to acute ACTH stimulation
If it were possible to measure serum cortisol and plasma
ACTH immediately, the diagnosis and cause of adrenal
insufficiency could be established without delay in most
cases.
Unfortunately, plasma ACTH results are usually not rapidly
available, and it is often important to determine quickly
whether primary adrenal insufficiency is the cause.
This can be done indirectly by stimulating the adrenal gland
with exogenous ACTH. The ACTH value, generally available
later, can be used to establish the level of the defect.
Laboratory Diagnosis of adrenal insufficiency

• Short ACTH stimulation tests

• A short ACTH stimulation test should be performed in all
patients in whom the diagnosis of adrenal insufficiency is
being considered.
• The agent used is synthetic ACTH. In healthy individuals,
cortisol responses are greatest in the morning, but in patients
with adrenal insufficiency the response to cosyntropin is the
same in the morning and afternoon. As a result, it is best to
perform the test in the morning to avoid a falsely abnormal
result in a healthy subject.
Laboratory Diagnosis of adrenal insufficiency

• A normal response to the high-dose (250 mcg as an iv bolus)

ACTH stimulation test is a rise in serum cortisol concentration
after 30 or 60 minutes to a peak of 18 to 20 mcg/dL or more.
• The low-dose ACTH stimulation test criteria for a normal
cortisol response after 20 or 30 minutes are more variable: 17
to 22.5 mcg/dL.
• For both tests, a subnormal response confirms the diagnosis
of adrenal insufficiency, but further studies are necessary to
establish its type and cause.
Laboratory Diagnosis of adrenal insufficiency

• A normal response to the high-dose (250 mcg) ACTH

stimulation test excludes primary adrenal insufficiency and
most patients with secondary adrenal insufficiency.
• An abnormal response to this test is very helpful for
establishing the diagnosis of adrenal insufficiency and a
normal response excludes the diagnosis of primary adrenal
insufficiency but a normal response does not exclude the
diagnosis of secondary adrenal insufficiency
Laboratory Diagnosis of adrenal insufficiency

• Secondary adrenal insufficiency — 

• The high-dose ACTH test does not entirely exclude chronic
partial pituitary ACTH deficiency, or that of recent onset (eg,
within one to two weeks after pituitary surgery). In such
patients, the adrenal glands have not yet become completely
atrophic, and are still capable of responding to ACTH
stimulation
• In these cases only an insulin-induced hypoglycemia or
metyrapone test is completely reliable.
Laboratory Diagnosis of adrenal insufficiency

• ESTABLISHING THE LEVEL OF DEFECT

• Cortisol secretion is deficient in patients with primary adrenal
insufficiency despite the fact that their ability to secrete ACTH
is intact.
• Conversely, patients with secondary or tertiary adrenal
insufficiency have intrinsically normal but atrophic adrenal
glands that are capable of producing cortisol but fail to do so
because ACTH secretion is deficient.
Laboratory Diagnosis of adrenal insufficiency

• Basal plasma ACTH concentration

• Measurement of the basal plasma ACTH concentration can
usually distinguish between these disorders if the reference
laboratory's ACTH assay is reliable.
• When coupled with simultaneous measurement of basal
serum cortisol, measurement of plasma ACTH may both
confirm the diagnosis of adrenal insufficiency and establish its
cause.
Laboratory Diagnosis of adrenal insufficiency

• In primary adrenal insufficiency, the 8 AM plasma ACTH

concentration is high, similarly, plasma renin concentration or
activity will be elevated, while aldosterone levels will be
lower. In contrast, plasma ACTH concentrations are low or low
normal in secondary or tertiary adrenal insufficiency. Plasma
levels of renin and aldosterone are usually unaffected in
secondary or tertiary adrenal insufficiency, but
mineralocorticoid deficiency can sometimes occur after very
prolonged deficiency of ACTH.
Laboratory Diagnosis of adrenal insufficiency

• Because glucocorticoid treatment will suppress the ACTH

secretion, blood samples for ACTH determination must be
drawn before initiating glucocorticoid therapy or, in patients
already being treated, at least 24 hours after the last dose of a
short-acting glucocorticoid such as hydrocortisone, and even
longer after long-acting glucocorticoids such as
dexamethasone.
Laboratory Diagnosis of adrenal insufficiency

• Response to prolonged ACTH stimulation

• Prolonged stimulation with exogenous ACTH also will
distinguish between primary and secondary or tertiary
adrenal insufficiency.
• The atrophic adrenal glands in secondary or tertiary adrenal
insufficiency recover cortisol secretory capacity if chronically
exposed to ACTH, whereas the adrenal glands in primary
adrenal insufficiency are partially or completely destroyed,
are already exposed to maximally stimulating levels of
endogenous ACTH, and cannot respond to additional ACTH.
Laboratory Diagnosis of adrenal insufficiency

• Because this test requires hospitalization, and is more

expensive than measurement of plasma ACTH, it is rarely used
except in complicated clinical settings or when the ACTH or
cortisol results are non-diagnostic. As an example, a patient
treated for presumed adrenal insufficiency may have
secondary adrenal insufficiency as a result of treatment.
Laboratory Diagnosis of adrenal insufficiency

• This test is performed by administering ACTH (250 mcg daily)

as a continuous infusion or for eight hours each day, for 48
hours while measuring urinary 17-OHCS or cortisol excretion
and the serum cortisol daily. There is a progressive increase in
cortisol secretion in secondary or tertiary adrenal
insufficiency, but little or no response in primary adrenal
insufficiency.
Laboratory Diagnosis of adrenal insufficiency

• Metyrapone tests
• The metyrapone tests may be useful in occasional patients in
whom partial ACTH deficiency is suspected, particularly in
postoperative pituitary surgery patients and others with
partial secondary adrenal insufficiency.
Laboratory Diagnosis of adrenal insufficiency

• Metyrapone blocks the final step in cortisol biosynthesis,

resulting in reductions in cortisol secretion and the serum
cortisol concentration, and stimulation of ACTH secretion in
response to the decrease in cortisol negative feedback
inhibition.
• Hypocortisolemia is not as strong a stimulus to ACTH
secretion as is stress, such as that caused by hypoglycemia. As
a result, the metyrapone test will detect partial ACTH
deficiency that may be missed by the standard ACTH
stimulation test or the insulin-induced hypoglycemia test.
Laboratory Diagnosis of adrenal insufficiency

 Insulin-induced hypoglycemia test 

 Although insulin-induced hypoglycemia is a valid, and perhaps
the most rational, test of hypothalamic-pituitary-adrenal
response to stress, there is little, if any, reason for performing
the test except in patients with suspected recent ACTH
deficiency, or in patients with suspected growth hormone and
ACTH deficiency.
 Insulin (usually at a dose of 0.15 U/kg) is given with the aim to
achieve hypoglycemia of 35 mg/dL (1.9 mmol/L) or less.
Cortisol concentrations are measured at 0,30 and 45 minutes,
even if glucose has been given to reduce symptoms of
hypoglycemia.
Laboratory Diagnosis of adrenal insufficiency

• Corticotropin-releasing hormone test

• The differentiation between secondary and tertiary adrenal
insufficiency can made by the administration of corticotropin-
releasing hormone (CRH), although from a therapeutic
standpoint this distinction is seldom important.
• There is little or no ACTH response in patients with secondary,
or pituitary-related, adrenal insufficiency, whereas patients
with tertiary disease due to lack of CRH from the
hypothalamus usually have an exaggerated and prolonged
ACTH response.
Laboratory Diagnosis of adrenal insufficiency

• DETERMINING THE ETIOLOGY

• Primary adrenal insufficiency — The patient's age and
gender, the clinical setting and the presence of other
autoimmune-mediated endocrine disorders are important in
the evaluation of patients with primary adrenal insufficiency.
• Abdominal CT should be performed since it can detect
enlarged adrenal glands or adrenal calcification; these
findings eliminate autoimmune disease and suggest an
infectious, hemorrhagic, or metastatic cause.
Laboratory Diagnosis of adrenal insufficiency

• Autoimmune adrenal insufficiency

• The diagnosis of autoimmune adrenal insufficiency is based
upon the presence of associated autoimmune disorders and
the exclusion of other causes.
THE END.....