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🏥 ADRENAL GLANDS - Exam Notes

1. CUSHING'S SYNDROME (Cortisol Excess)

Causes:

Iatrogenic - long-term glucocorticoid therapy (most common)
Adrenal tumor - excess cortisol production
Pituitary tumor (Cushing's Disease) - excess ACTH → stimulates adrenal cortex
Ectopic ACTH - tumor elsewhere producing ACTH

Clinical Features:

Moon face, buffalo hump, supraclavicular fat pad
Central obesity + thin limbs
Purple striae (abdomen/axilla), easy bruising
Plethora (red round face)
Hirsutism, female balding
Muscle weakness, fatigue
HTN, DM, poor wound healing
Amenorrhea, decreased libido
Severe depression, mood swings
Blurry vision

Diagnosis:

24-hour urinary cortisol
Low-dose dexamethasone suppression test
MRI

Treatment:

Depends on cause: surgery / radiation / chemo / cortisol-inhibiting drugs
Iatrogenic → gradually reduce steroid dose; switch to alternate-day dosing

2. HYPERALDOSTERONISM

Primary (Conn's Syndrome)

Causes: Aldosteroma (adenoma), adrenocarcinoma - usually unilateral, <4cm

Key Labs: Aldosterone ↑, K ↓, Na ↑, Renin ↓, Hypokalemic alkalosis

Clinical Features:

Resistant hypertension
Eye changes, cardiac hypertrophy
Neuromuscular: weakness, paresthesia, fatigue, cramps
Renal: polyuria (up to 4L), polydipsia, nocturia, mild proteinuria

Treatment:

Surgical resection (aldosteroma)
Subtotal/total adrenalectomy for hyperplasia if spironolactone fails

Secondary Hyperaldosteronism

Cause: Prolonged angiotensin II stimulation

Key differences from Primary:

Edema/swelling
No hypertension
Hypokalemia, hyponatruria
Causes: cardiac insufficiency, decompensated DM

3. ADRENAL INSUFFICIENCY

Chronic (Addison's Disease-type)

Causes: Autoimmune or tuberculous damage

Primary - adrenal pathology → ↓ cortisol, ↓ aldosterone, ↓ androgens
Secondary - ↓ ACTH
Tertiary - ↓ CRH

Clinical Features:

Weakness, fatigue, weight loss (adults don't lose weight initially)
Nausea, vomiting, abdominal pain, low appetite
Hyperpigmentation (primary only - due to ↑ ACTH/MSH)
Hypoglycemia, anemia, hypothermia
Newborns: fail to gain weight
Hypogonadism, steroidogenesis disorder

Associated Syndromes:

APS1 (10-12 yrs): Adrenal insufficiency + Hypoparathyroidism + Candidiasis
APS2:
- Adrenal insufficiency + AIT = Carpenter's syndrome
- Adrenal insufficiency + DM1 = Schmidt's syndrome

Labs:

Cortisol ↓, K ↑, Na ↓
ACTH ↑ (primary) / ACTH ↓ (secondary)
CT: Primary = adrenal hypertrophy; Secondary = adrenal atrophy

Treatment:

Glucocorticoid replacement (lifelong) ± mineralocorticoid
Rehydration
Treat hypoglycemia/collapse

Adrenal Crisis (Acute)

Triggers: Infection, trauma, surgery, stopping therapy, inadequate therapy

Clinical Features:

Cardiovascular: collapse, acute cardiac insufficiency
GI: nausea, vomiting, acetone smell, diarrhea, anorexia, abdominal pain
Neuro: asthenia, adynamia, depression

Emergency Treatment:

IV glucocorticoids immediately
Rehydration

Waterhouse-Friderichsen Syndrome (Acute Primary Adrenal Insufficiency)

Occurs after: difficult deliveries, septic infections, acute DIC, adrenal vascular thrombosis
Acute glucocorticoid deficiency WITHOUT prior chronic insufficiency
Features: deep resistant hypotension/collapse, pulmonary edema, dehydration → can be fatal
Also: nausea, vomiting, diarrhea, visual hallucinations
Treatment: Rehydration + glucocorticoid replacement

4. PHEOCHROMOCYTOMA

Definition: Tumor of adrenal medulla → excess catecholamine production

Key feature: Symptoms triggered by physical activity, position change, medical manipulation

Clinical Types:

Type	Features
Adrenalosympathetic (Paroxysmal)	Hypertensive crises; sudden onset; pallor, irritability, fear, fever; BP rapidly swings from high to low; fatal without treatment
Continuous	Rare crises (mainly children); resembles malignant HTN; nephrosclerosis, MI; sometimes + DM
Nonsymptomatic	Rare; triggered by stress (surgery, trauma, delivery)

Complications: MI, heart failure, pulmonary edema, hypertensive encephalopathy, stroke, carbohydrate intolerance

Diagnosis:

Metanephrines in urine
Ultrasound / CT / MRI / Screening

Treatment:

Alpha-adrenoblockers: IV → IM (every 2-4h) → oral (after 3-6h)
Adrenalectomy if hemodynamics uncontrollable

🧬 ADRENAL 2 - Congenital & Developmental Disorders

5. CONGENITAL ADRENAL HYPERPLASIA (CAH) - 21-Hydroxylase Deficiency

Most common form. Caused by CYP-21 mutation. Result: ↓ cortisol, ↓ aldosterone, ↑ androgens (ACTH goes up → adrenal hyperplasia)

A) Salt-Losing Syndrome (Complete 21-OH deficiency)

Complete loss of 21-hydroxylase → Aldosterone ↓ → Na lost through kidneys, Hyperkalemia
Onset: 3-4 days after birth
Symptoms: Weight loss, projectile vomiting, dry skin, low BP, bradycardia, cyanosis, hyperpigmentation, adynamia
Girls: ambiguous genitalia; Boys: normal genitalia
Labs: K ↑, Na ↓, Hypoglycemia, 17-OH Progesterone ↑, Karyotype
Treatment: Glucocorticoids + Mineralocorticoids

B) Viril (Simple Virilizing) Type

Girls: from birth; Boys: 2-5 years old
Girls: ambiguous genitalia; Boys: normal
Accelerated growth, premature puberty, hyperpigmentation
Acute adrenal insufficiency may occur under stress
Labs: K normal, Na normal, 17-OH Progesterone ↑
Treatment: Glucocorticoids only

C) Nonsymptomatic (Late-Onset) Type

Presents at prepuberty
Normal genitalia
Girls: virilism, hirsutism, early adrenarche, late menarche
Boys: no symptoms / sometimes gynecomastia
Labs: 17-OH Progesterone normal or mildly ↑, moderate bone age delay
No treatment noted (monitoring)

6. HYPOGONADISM

Types:

Type	Subcategory	Examples
Hypogonadotropic (↓ LH/FSH)	Constitutional delay	Normal variant
	Congenital	Kallmann syndrome, Prader-Willi, LH receptor defect
	Acquired	Craniopharyngioma, adenoma, glioma, CNS infection/radiation
Hypergonadotropic (↑ LH/FSH)	Congenital	Klinefelter, Turner, anorchism, steroidogenesis damage
	Acquired	Gonadal infection, radiation, autoimmune, iatrogenic castration

7. KLINEFELTER SYNDROME (47, XXY)

Males with extra X chromosome
Primary features: infertility + small testicles
Taller stature, poor coordination, weaker muscles
Gynecomastia, reduced body hair, low libido
Usually normal intelligence; speech/reading problems common
Hormones: Hypergonadotropic hypogonadism (↑ FSH, LH; ↓ testosterone)

Complications: Infertility, autoimmune disorders, breast cancer, VTE, osteoporosis

Treatment: Testosterone replacement therapy

8. TURNER SYNDROME (45, XO)

Females partly/completely missing one X chromosome
Features: Short stature, webbed neck, low-set ears, low posterior hairline, swollen hands/feet at birth
Lymphostasis
Hormones: Hypergonadotropic hypogonadism (no functional ovaries)
No spontaneous puberty/menstruation without hormones; infertile (need ART)
Associations: Heart defects, DM, hypothyroidism, vision/hearing problems
Normal intelligence; difficulties with spatial visualization/math

Diagnosis: Ultrasound + clinical + hormonal + Karyotype

Treatment: Estrogen replacement + Growth hormone

⚡ QUICK RECALL TABLE

Condition	Key Hormone	Key Lab Change	Key Drug
Cushing's	↑ Cortisol	-	Glucocorticoid inhibitors
Conn's	↑ Aldosterone	K↓, Renin↓	Spironolactone / Surgery
Addison's	↓ Cortisol	K↑, Na↓	Hydrocortisone
Pheo	↑ Catecholamines	Metanephrines in urine	Alpha-blockers
CAH	↑ Androgens	17-OH Prog ↑	Glucocorticoids
Klinefelter	↓ Testosterone	↑ FSH/LH	Testosterone
Turner	↓ Estrogen	↑ FSH/LH	Estrogen + GH

Good luck on your exam tomorrow! These notes cover everything in both slides - the key patterns to remember are cortisol excess (Cushing's) vs. deficiency (Addison's), the aldosterone axis (Conn's), pheo triggers/crises, and the chromosome numbers for Klinefelter (47,XXY) and Turner (45,XO).

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