Adrenal Disorders

Definition

Presenting signs and symptoms of adrenal disorders are those of excessive or insufficient hormone production. Addison’s disease implies adrenal gland damage thus causing aldosterone, adrenal androgen, and cortisol deficiency. Overproduction can be that of glucocorticoid (Cushing syndrome), mineralocorticoid, or catecholamine.

Symptoms

Adrenal insufficiency: Dizziness, fatigue, weakness, abdominal pain, nausea, vomiting, fever, hyperpigmentation (nails, palmar creases), and salt craving.

Adrenal excess: Weakness, weight gain, hirsuitism, skin infections, acne, emotional instability, palpitations, headaches, and diaphoresis.

General: The symptoms may be insidious. New onset weight gain or loss, glucose intolerance, or hypertension may indicate glucocorticoid, mineralocorticoid, or catecholamine excess. Inadequate adrenal hormone production may not be noted until a stressful event (e.g., myocardial infarction, pneumonia) precipitates a crisis.

Age: Any, although more common in adults and women.

Onset: Gradual to acute.

Duration: Months to years.

Intensity: Asymptomatic to acute crisis.

Aggravating Factors

Adrenal insufficiency: Stress, illness, trauma, or dehydration.

Adrenal excess: Medical illness requiring large dose steroid therapy (systemic lupus erythematosus, organ transplants). Use of beta blockers in the presence of pheochromocytoma may cause an increase in blood pressure.

Symptoms

• Adrenal insufficiency: Dizziness, fatigue, weakness, abdominal pain, nausea, vomiting, fever, hyperpigmentation (nails, palmar creases), and salt craving.
• Adrenal excess: Weakness, weight gain, hirsuitism, skin infections, acne, emotional instability, palpitations, headaches, and diaphoresis.
• General: The symptoms may be insidious. New onset weight gain or loss, glucose intolerance, or hypertension may indicate glucocorticoid, mineralocorticoid, or catecholamine excess. Inadequate adrenal hormone production may not be noted until a stressful event (e.g., myocardial infarction, pneumonia) precipitates a crisis.

Age:Any, although more common in adults and women.

Onset: Gradual to acute.

Duration: Months to years.

Intensity: Asymptomatic to acute crisis.

Aggravating Factors

Adrenal insufficiency: Stress, illness, trauma, or dehydration.

Adrenal excess: Medical illness requiring large dose steroid therapy (systemic lupus erythematosus, organ transplants). Use of beta blockers in the presence of pheochromocytoma may cause an increase in blood pressure.

Alleviating Factors

• Adrenal insufficiency: Correction of underlying medical illness, replacement of hormone.
• Adrenal excess: Tapering of hormone replacement or removal of adrenal tumors.
• Associated Factors Adrenal insufficiency: Need to check if mineralocorticoid (aldosterone) insufficiency is severe enough to cause hypotension, salt loss, or hyperkalemia. Exclude pituitary insufficiency with lack of adrenocorticotrophic hormone (ACTH), thus exhibiting cortisol insufficiency, but not mineralocorticoid insufficiency (mineralocorticoid system would still be intact since this system does not require ACTH and reninangiotensin system can continue to stimulate aldosterone release).
• Adrenal excess: Endocrine excess from the adrenal gland may be due to pheochromocytoma causing hypertension. If a pituitary adenoma causes ACTH secretion (Cushing’s disease), bilateral adrenal hyperplasia may result. Secondary hyperaldosteronism (not due to adrenal tumor) may occur with renal artery stenosis, diuretics, volume depletion, or ectopic ACTH secretion.

Physical Examination

General

• Adrenal insufficiency: The patient may appear normal or have labile emotions.
• Adrenal excess: Patient may have obvious signs of truncal obesity with a buffalo hump, hirsuitism, extremity muscle wasting, acne, or have labile emotions.

Cardiovascular

• Adrenal insufficiency: Hypotension may be present due to cortisol or mineralocorticoid deficiency.
• Adrenal excess: Hypertension may be seen with mineralocorticoid, glucocorticoid, or catecholamine excess.

Extremities

• Adrenal insufficiency: Increased pigmentation (see skin examination).
• Adrenal excess: Muscle wasting and fungal infections in nails or skin are seen in Cushing’s disease.Head, Eyes, Ears, Nose, and Throat (HEENT)
• Adrenal excess: Buffalo hump, moon facies, and cataracts may be seen with cortisol excess.

Genitourinary

• Adrenal excess: Fungal infections with Cushing’s disease.
• Neuropsychiatric Adrenal insufficiency: Labile emotions.
• Adrenal excess: Depression, labile emotions, hallucinations with high cortisol levels.

Skin

• Adrenal insufficiency: Evaluate for hyperpigmentation in the palmar creases, fingernails, elbows, knees, buccal mucosa, areolae, and nipples (due to elevated ACTH levels). Axillary and pubic hair may be less prominent in females due to a lack of adrenal androgens.
• Adrenal excess: Striae, acne, hirsuitism, easy bruiseability, and thin skin are all seen due to elevated glucocorticoid.

Pathophysiology

• Adrenal insufficiency: Autoimmune damage to the adrenal gland is the most common cause of primary adrenal insufficiency (approximately 80 percent of cases). Other causes include tuberculosis, heparin therapy, trauma, metastatic carcinoma, fungal infections and complications of acquired immunodeficiency syndrome (AIDS). For secondary adrenal insufficiency, the cause is lack of ACTH due to pituitary or hypothalamic dysfunction.
• Adrenal excess: Cushing syndrome refers to patient presentations with steroid excess. Cushing’s disease is specifically due to ACTH excess of pituitary origin with high glucocorticoid levels. Adrenal tumors, ectopic ACTH production, and bilateral nodular hyperplasia may all cause Cushing syndrome. Mineralocorticoid excess may be primary (adrenal adenoma or hyperplasia) or secondary (reno vascular diseases, high renin states). High levels of glucocorticoids have a mineralocorticoid effect. Pheochromocytoma is a rare endocrine tumor that may cause hyper