Disclaimer : Property of Department of Endocrinology, Zagazig University

2. ADRENAL
CORTEX
By
Khaled Hadhoud
A.PROF. of Internal
Medicine
Endocrinology unit
Zagazig University

3. Physiological
considerations :
1. Zona glomerulosa:  secretes aldosterone
Na & H2O retention.

4. 2. Zona fasciculata :  secretes glucocorticoids,
mainly cortisol (hydrocortisone ).
Metabolic effects of cortisol
• On fat (in excess)  mobilization & deposition in
abnormal sites.
• On proteins  catabolic, (in excess)  muscle
wasting & osteoporosis.
• On carbohydrates : ↑ gluconeogenesis & ↓
glucose uptake by the muscle cells, (in excess) 
hyperglycaemia.
• On H2O & electrolytes  Na & H2O retention & K
excretion. o On blood (bone marrow) ↑RBCs & ↓
eosinophils & lymphocytes.
• Androgenic.
• Anti-allergic (tend to – Ag - Ab reaction).
• Anti - inflammatory (& in excess - fibrous tissue
formation & destroys elastic fibers ).

5. N.B.:
• Zona fasciculata is under the control of
ACTH.
• ACTH is derived from a large precursor
molecule which also gives rise to melanocyte
stimulating hormone, lipotropin & endorphins
(POMCpro-opio-melano-cortin).
3. Zona reticularis :
• Secretes sex hormones, mainly androgens &
small amount of oestrogen & progesterone.
• The main androgen is dehydro-
epiandrosterone which enhances protein
anabolism & promotes the development of
male 2ry sexual characters "& sexual hair in
♀.
• The end products of androgens are 17
ketosteroids ( which are excreted in urine).
• It is under the control of A.C.T.H.
N.B.
• Sources of androgens:
• In ♂  (adrenal, testes).
• In ♀  (adrenal).

6. CONN'S SYNDROME
(1ry
hyperaldosteronism )
Causes:
• Adrenal aldosterone producing
adenoma (60%).
• Hyperplasia of zona
glomerulosa (bilateral)(40%).
• Aldosterone producing
carcinoma (rare).

7. Clinical picture:
1. Hypertension : may be severe, due to
 Na retention.
2. Hypokalaemia : leading to :
• Apathy, Paraesthesia.
• Arrhythmias as extrasystoles.
• Atony of intestine  constipation &
even paralytic ileus.
• Muscle weakness & even episodic
paralysis (& if the respiratory
musclesare affected  dyspnea).
• Impaired glucose tolerance (in 50%)
because K has a direct effect on
insulin release from B cells & may
influence insulin action.

8. 3. Alkalosis "metabolic": Due to
heavy loss of H+ in urine  tetany.
4. Absence of oedema : due to
K diuresis  polyuria.
Impaired tubular reabsorption of
water (renal concentration defect)
 polyuria "due to prolonged
Hypokalaemia".

9. • Investigations:
1. Biochemical changes :
• Hypokalaemia (N = 3.5 - 5 mEq / L ).
• Hypenatraemia (N = 140 mEq /L ).
• Alkalosis ( ↑serum Hco3 mEq/L) (N=22-
30 mEq /L)
2. Urinary changes:
• Polyuria.
• ↑ K, ↓Na.
• ↑ aldosterone excretion ( N = 12 - 50 ug
/ 24 hs).
3. Measurement of plasma level of:
• Renin : ↓ in 1ry hyperaldosteronism
( & remains low on Na restriction ).

10. N.B.
• Plasma renin level is high in cases of 2ry
hyperaldosteronism.
– You must stop ttt of HPN before
measurement of renin
• Aldosterone : high despite high Na load
(N=3 - 15ng/dl)
N.B.
• In 2ry hyperaldosteronism, aldosterone level can
be ↓by Na load.
• 4. U/S& adrenal CT.

11. Differential diagnosis :
a. From hypertensive conditions
associated with Hypokalaemia :
• Hypertension "malignant or renal" with
2ry hyperaldosteronism.
• Diuretics causing Hypokalaemia in
hypertensive patient.
• Cushing syndrome, CAH & rarely
Juxtaglomerular hyperplasia.
• Intake of exogenous
mineralocorticoids.
• K-losing nephropathies causing or
associated with HPN e.g. bartter's
syndrome, Liddle's syndrome.
b. From other causes of
Hypokalaemia & familial periodic

12. Treatment:
Surgical removal of the adenoma
(after correction of the electrolyte
imbalance).
Medical ttt:
• In bilateral adrenal hyperplasia.
• Amiloride (40mg/day) is preferable
to spironolactone (which leads to
gynaecomastia & impotence on
chronic use ).

13. CUSHING'S
SYNDROME
Causes:
Endogenous Cashing syndrome "
rare, yearly incidence of one/million".
Pituitary cushing syndrome
(cushing disease ).
• The most common cause of
endogenous Cushing (75 %).
• 80 % are caused by pituitary basophil
micro-adenoma secreting excessive of
ACTH " the remaining cases may be of
hypothalamic origin".
• it is commoner in ♀ than ♂.

14. Adrenal Gushing syndrome : (20
%)
• Caused by autonomous cortisol
production from adenoma, carcinoma
or hyperplasia of adrenals.
Ectopic Gushing syndrome :
( autonomous ACTH production ) e.g.
• Bronchogenic carcinoma, pulmonary
carcinoid.
• Thymoma, ovarian or pancreatic
carcinoma.

15. ExogenousExogenous
CashingCashing
syndromesyndrome ""
CushingoidCushingoid
syndrome "syndrome "
ProducedProduced
by prolongedby prolonged
use ofuse of
corticosteroids.corticosteroids.

16. Clinical picture:
Abnormal deposition of fat in
certain sites :
• In the face  becomes rounded
with bloated cheeks ( Moon face).
• In the interscapular region 
(Buffalo hump).
• In the breasts & abdomen 
(Trunkal obesity), but the buttocks
are hollow with thin limbs (lemon
on match sticks).

18. Disturbances in protein
metabolism :
• ↑protein catabolism  muscle
wasting & weakness (even proximol
myopathy).
• Osteoporosis :
• Kyphosis, shortening
• Pathological fractures.
• Bruises & purpura (due to ↓support of
blood vessels).
• Delayed healing of wounds.
• Stria rubra:
• Due to rupture of weakened s.c. collagen
fibers (together with fat mobilization) 
purplish lines in the skin around the

20. Disturbances in carbohydrate
metabolism :
• Hyperglycaemia & may end in
D.M. (in 15% of cases) which is
somewhat insulin resistant
(steroid diabetes)
Disturbances in fluid &
electrolytes balance :
• Na retention hypertension.
• Hypokalaemia  polyuria,
alkalosis.

21. Sexual manifestations :
• In females
• Amenorrhea.
• Acne.
• Hirsutism.
• In males
↓sexual desire,
Impotence ↑estrogen.

22. General manifestations
• Plethoric face due to
polycythaemia.
• Psychiatric disturbances:
common, usually in the form of
depression.
• Obesity & stunted growth may
be the main presenting feature
in childhood.

23. Features suggesting the
aetiology :
• Evidence of virilizatation (Is most
common in)  adrenal carcinoma.
• Hypokalaemic alkalosis, myopathy &
hyperpigmentation (occur most often
in)  Ectopic Cushing syndrome ( the
distinguishing clinical features of
hypercortisolism are often absent).
• Age & sex :
• Children (more common in)  adrenal
carcinoma.
• Adult ♂  Ectopic Cushing.
• ♀ in childbearing age "  pituitary
Cushing.

25. Investigations:
Investigations which
suggest cushing syndrome :
• Hypokalaemic alkalosis,
Hypernatraemia.
• Blood picture ↑RBCs,
↓lymphocytes & eosinophils.
• Impaired glucose tolerance.
• X-ray  osteoporosis &
unsuspected fractures.

26. Investigations which confirm
cushing syndrome.
• Plasma cortisol level :(N=5-20ug/dl) " at
8 AM "
The earliest indication of increase
cortisol secretion is loss of the diurnal
variation (circadian rhythm) " normally,
plasma cortisol level at 4 p. m. is <
50% of that at 8 a.m
N.B.
• Then, there is persistent elevation.
• Recently diurnal variation can be
detected by salivary cortisol.

27. • Urinary steroid excretion :
Hydroxy corticosteroids (17 oH Cs).
Urinary free cortisol excretion (the
most reliable index of
hypercortisolism).
• Overnight dexamethasone
suppression test:
Dexamethasone 1 mg is given orally
at night ( 11 pm ) & plasma is
obtained at 8 am the following
morning  cortisol level <7ug/<dL
exclude hypercortisolism.

28. Investigations to differentiate
between the 3 forms of cushing
syndrome:
• Plasma ACTH:
Very high  in Ectopic Gushing.
High  in pituitary Cushing.
Low or absent  in adrenal Cushing.
• CRH stimulation test: (1ug/kg I.V.)
ACTH & cortisol levels  in pituitary
Cushing.
No effect —> in Ectopic or adrenal.

29. • High dose dexamethasone suppression test:
2 mg / 6 hours for 2 days is given orally.
In pituitary Cushing  50 % ↓of 24 hours
excretion of 17 OHCs or the plasma cortisol.
In adrenal or Ectopic Cushing  no effect.
N.B. BIPSS
• Localization procedures :
Abdominal U/S & C.T. of adrenals  for
adrenal tumours.
Sellar X-ray detects 10 - 15 % of pituitary
tumours & C.T. detects 85% of
microadenomas ( MRI is better ).
Chest x-ray -. for bronchial carcinoma.

30. Differential
diagnosis:• Exogenous obesity, essential HPN &
D.M. occurring separately or
combined :In such cases :
• Obesity is generalized.
• Plasma cortisol & urinary end products 
normal.
• Other causes of obesity : e.g.
Myxoedema, Frohlich's syndrome, ..etc
• Other causes of Hirsutism.
• Other causes of osteoporosis.

31. • Women on oral oestrogen - containing
C.C.P.s may become overweight & may
have higher levels of plasma cortisol
(due to↑cortisol binding globulin).
• Patients suffering from LCF may
develop Cashing - like manifestations
due to impaired cortisol metabolism. In
such cases, plasma cortisol level is
raised but, manifestations of LCF are
prominent.

32. N.B.
• Pseudo - Cushing syndrome :
Chronic alcoholism, acute
severe illness, obesity &
depression may be associated
with mild ↑in cortisol levels &
absent diurnal variation.

33. Treatment:
Pituitary Cushing :
Surgery :
• Trans-sphenoidal hypophysectomy.
• Remission (85%).
• Complications...
Irradiation : e.g. Proton beams, alpha particles.
After ttt Cortisone for life.
Medical:
• Drugs that inhibit ACTH release e.g
CYPROHEPTADINE,VALPROATE;
BROMOCRIPTINE .
• Drugs that inhibit steroidogenesis e.g
KETOCNAZOL.

34. Adrenal Cushing :
Adrenal adenoma:  removal.
N.B.
• Post-operative glucocorticoids replacement is
necessary for several months until function
returns in contralateral previously suppressed
gland.
Adrenal carcinoma  removal.
• Preoperative ttt.: with enzyme inhibitor "
Metyrapone"
11 deoxycortisol cortisol
• Post-operative : Give mitotane " for residual
disease.

35. Ectopic Cushing :
• Surgical removal of the
tumour. Or
• Metyrapone ± Mitotane.

36. ADDISON'S DISEASE
Chronic adrenal failure = adrencortrical
insufficiency
= adrenal hypocorticism
Causes :
• 1. Auto-immune adrenalitis : ( most common cause,
70%)
N.B.
This may occur alone or in combination with other auto-
immune endocrine insufficiency including IDDM,
hypothyroidism (& sometimes hypogonadism,
Hypoparathyroidism or pernicious anaemia ) " Schmidt
syndrome " .
• 2. T.B. of the adrenal glands (10-20%).
• 3. Following bilateral adrenalectomy & congenital
enzymatic defects.
• 4. Sarcoidosis, secondaries, amyloidosis or
haemochromatosis (rare causes ).

37. Clinical picture:
Onset is usually insidious, mostly in the adult
life & the course is slowly progressive.
• Asthenia :
Weakness of muscles; Weight loss.
Due to : * Lack of cortisol.
* Hyperkalaemia.
* Hypoglycaemia.
+ muscles cramps due to hyponatraemia.

38. • Hypotension
Systolic blood pressure > 110
mmHg excludes Addison's
disease.
Postural hypotension 
common due to hypovalaemia &
dehydration.
• Hypoglycaemia: leading to:
Drowsiness, hunger pain & even
coma.

39. • Hyperpigmentation: of skin & m.m.
Sites :
• Face, neck, groins, axillae, nipples,
friction areas, scars as umbilicus, areas
exposed to sunlight.
• m.m. of mouth, tongue, rectum (state
coloured patches).
Causes :
• Hypocorticism  ACTH ↑melanocyte
stimulating hormone (& lipotropin) ↑
pigmentation.
• Destruction of the adrenal medulla : 
diversion of tyrosine to form melanin
instead of adrenaline & noradrenaline.

40. N.B.
• Leucoderma may occur as a
part of autoimmune
disturbance.
• Hyperpigmentation isn't a
feature of Simmond's ,
disease.

42. • Loss of adrenal androgen :
• ↓axillary & pubic hair in ♀(but in ♂, testicular
androgen is preserved).
• Infertility & amenorrhea in females.
• GIT disturbances :
• Nausia, vomiting, diarrhea (& even steatorrhea).
• Polyuria : due to Na diuresis .
• There may be tenderness in the renal angle in
T.B. of adrenals.
N.B.
The patients may present with Addisonian
crisis ( see later ).

43. Investigations:
• ↓plasma cortisol level.
• ↓24 hour urinary cortisol, 17 oHCs
or 17 Ks ( ketosteroids ).
• ACTH stimulation test " synacthen
test" ( 0.25 mgI.M. or I.V.)
• Normal response  plasma cortisol ↑by
6 ug / dl above the basal value.
• In 1ry adrenal insufficiency  no
response.
• In 2ry adrenal insufficiency  normal
response

44. •
Biochemical changes :
• ↓serum Na, Cl
• ↑ serum K, acidosis.
• ↑serum Ca.
• ↓ serum glucose.
• Urine:
• ↑volume.
• ↑Na & Cl & ↓K excretion.
• Blood picture:
• Normochromic anaemia.
Haemoconcentration ,Eosinophilia &
lymphocytosis.

45. • Investigation to find the
cause :
• Adrenal antibodies - in 
autoimmune Addison.
• X-ray:
- adrenal calcification in T.B. cases.
- evidence of pulmonary T.B.

47. Differential
diagnosis:
• D.D. from 2ry hypo – adrenalism
• Other causes of pigmentation e.g.
racial, haemochromatosis, porphyria &
ancanthosis nigricans,
neurofibromatosis.
• Asthenia & pigmentation may occur
also in : e.g. pellagra, CML (especially,
in patients on busulfan therapy), CRF,
chronic arsenic poisoning,
thyrotoxicosis, advanced malignancy,
Malabsorption syndrome.

48. Treatment:
Replacement therapy :
• Glucocorticoids prednisolone 5 mg
in the morning & 2.5 mg in the
evening.
• Mineralocorticoids  fludrocortisone
0.1 mg every other day.
N.B.
• Active T.B. cases should receive
anti-T.B. therapy.

50. Acute Adrenal
Failure
Addisonian Crisis• Causes :
•In addison's disease :
• Previously undiagnosed patients may
present in crisis either spontaneously or
ppted by intercurrent illness.
• Patients already on ttt, on facing severe
intercurrent illness without increasing the
replacement dose.
•In sheehan syndrome  if
ttt is initiated with thyroxin alone
without cortisone.
• After bilateral adrenalectomy (
or pituitary surgery ).

51. • After sudden corticosteroid
withdrawal.
• Acute meningococcal septicaemia
(waterhouse friderichsen syndrome).
Hge may occur in the adrenal gland
acute adrenal failure.
• Medical ttt for adrenal carcinoma
( e.g. with metyrapone, mitotane ).
• Massive thrombosis of adrenal
veins ( during pregnancy, puerperium &
burns).

52. Clinical Picture:
• Sudden onset of severe
weakness, mental confusion,
abdominal pain, anorexia;
nausia, vomiting, diarrhea.
• Dehydration  shock.
• If not treated  coma & death
within 24 hours.

53. Investigations:
• ↓ serum Na.
• ↑ serum K.
• ↓serum cortisol.

54. Treatment of
addisonian crisis :
• Correction of volume depletion &
electrolyte status by I.V. saline &
glucose" 10 %".
• Hydrocortisone ( Solucortif)  100 mg
I.V. then 100 mg as I.V. infusion / 8 hours
(in 5 % glucose)  then gradual tapering (
until the maintenance dose is reached
within 5 days ).
• Fludrocortisone:  0.1mg/day (added-
when the daily dose of hydrocortisone
has reached 100 mg/day).
• Proper ttt of infections & precipitating
factor.

55.  Plasma 17-
hydroxyprogeste
rone is
elevated in
21(OH)ase ;
&11-
desoxycortisol
is elevated in
11(OH)ase

56. CONGENITAL ADRENAL
HYPERPLASIA
" Adrenogenital Syndrome
"
• Definition :
Group of condition caused by
inherited enzymatic defects in the
enzymes necessary for the synthesis
of cortisol ↓cortisol ↑ ACTH
adrenal hyperplasia & ↑synthesis of
the hormone proximal to the block.
• Causes :

57. Enzyme
↓
Hormonal
changes
Clinical
features
17 oH ase ↓"
extremely
rare"
↓ glucocorticoids &
sex hormones.
↑mineralocorticoids.
HPN & Hypokalaemia.
In females  sexual
infantilism.
In males 
♂pseudohermaphroditism
21 oH ase ↓, "
it is the
commonest
form "
↓ glucocorticoids
&
mineralocorticoi
ds.
↑sex steroids
Salt losing syndrome :
Due to aldosterone ↓:
Hypotension.
Hyperkalaemia
-
♀ pseudohermaphroditism
-♂ precocious puberty
11 B oH ase
↓"accounts for
↑11deoxycorticosterone,
deoxycortisol &
androgens.
↓cortisol
Hypertension.
Virilization  ♀
pseudohermaphroditism ♂

58. N.B.
• Pseudohermaphroditism : 
(phenotypic sex disturbance ).
• True hermaphroditism : 
(chromosomal sex disturbance).
[Differentiated by doing sex
chromatin pattern].

59. Treatment:
1. Replacement therapy :
• Prednisolone ( 7.5 mg / day ).
• To replace the deficient cortisol in
glucocorticoids deficient forms.
• --ACTH:
↓blood pressure in hypertensive
forms.
↓androgen in virilizing forms.
• Fludrocortisone (0.1mg/day) in
mineralocorticoid deficient forms.

60. Surgical correction :
• For ♀pseudohermaphroditism .
N.B.
In ♂ pseudohermaphroditism 
male functioning is impossible
& so female sex assignment is
advisable  surgical correction
of genitalia & gonadectomy are
required plus oestrogen
administration  relatively
normal but infertile ♀.