Adrenal Gland pathology: Here, we’ll take
a look at adrenal insufficiency and the various
Normal adrenal, a cartoon of… take a little
section of that adrenal gland and you blow
it up and you’ll find the cells to be perfectly
aligned and in proper organization.
A very common cause of adrenal gland destruction
would be autoimmune disease resulting in what’s
known as Addison’s.
Remember that Addison’s is a primary adrenal
insufficiency, this is an adrenal gland, but
this time around, our cartoon here on your
right column is showing you an amplified version
of a adrenal tissue in which we see antibody,
autoimmune disease, literally, autoimmune
disease in which it’s attacking the cells
of the adrenals causing complete annihilation
of the adrenals thus resulting in Addison’s
a.k.a. primary adrenal insufficiency.
What else may cause Addison’s?
Well, what about TB?
Tuberculosis may result in destruction of
your adrenal or you might have granulomatous
If you have infections resulting in maybe
Waterhouse–Friderichsen in which there is
acute haemorrhage into the adrenal gland causing
complete destruction of it and so, therefore,
You can have iron overload, maybe your patient
has an HFE gene that chromosome abnormality
called hereditary hemochromatosis or perhaps
has major, major type of anaemia or severe
anaemia such as beta thalassemia major and
therefore, warrants from the tender age of,
let’s say, six months or even younger upon
or with transfusion for 20 years taking such
transfusions may result in iron overload or
And hemochromatosis causing damage to many,
many, many, many organs including your heart,
including the pancreas, including the skin
or maybe perhaps, as shown here in the picture
exaggerated, iron overload.
So, our topic is primary adrenal insufficiency.
Autoimmune, it could be a part of and is part
of what’s known as polyglandular autoimmune
Multiple glands that are being destroyed by
autoimmune diseases, these include your thyroid
gland Hashimoto, hypothyroidism at least know
type I; speaking of which, here, we have type
I diabetes mellitus.
What kind of destruction to the pancreas?
And the trilogy of polyglandular the third
and final one would be the adrenal gland,
all part of polyglandular autoimmune endocrinopathy.
If you thought that MEN 1 and 2a and 2b was
hard enough to remember, add one more to your
list now… polyglandular autoimmune endocrinopathy.
Infections such as TB may cause a destruction
or bilateral adrenal haemorrhage can be part
of meningococcemia, Neisseria known as Waterhouse–Friderichsen
syndrome are resulting in primary adrenal
insufficiency during anticoagulation or perhaps
even in the setting of lupus anticoagulant.
All these may result in what’s known as
massive haemorrhage into both of the adrenals
causing massive primary adrenal insufficiency.
AIDS, amyloidosis, sarcoidosis, hemochromatosis
and metastatic cancer could all cause complete
destruction of the adrenals.
Pause here for a second.
We completed discussion of primary adrenal
insufficiency, let us now move on to secondary
Where’s my problem?
Maybe it’s a pituitary disease, what happened?
Sheehan, infarction, apoplexy, haemorrhage…
oh, maybe there is a non-functioning adenoma
within my pituitary resulting in hypofunctioning.
Long term exogenous steroid administration.
Now, pause here for a second; big time, pay
You’re giving your patient steroid.
“Dr. Raj, didn’t you say that that caused
the most common cause of Cushing’s?”
Yeah, what’s my topic here?
So, we’re going to walk through this in
great detail right now.
You’re giving your patient prednisone, why?
Oh, maybe because of needs of immunosuppression.
Maybe giving prednisone because you are taking
care of some type of inflammatory state long
term such as rheumatoid arthritis, okay?
So, you’re giving prednisone over a long
period of time, what’s your patient look
Moon facies, buffalo hump, trunk obesity,
purple striae, red striae; worst at extremities,
right, prototypical Cushing’s.
Can you now work with me what’s going on
inside the body?
So, you’re giving prednisone, a type of
glucocorticoid, what’s going to happen to
your levels of ACTH?
You’re going to suppress it, abnormal…
this patient has no more access, what do you
Access between the hypothalamus and the pituitary
and the adrenal… perfectly normal.
You’re giving prednisone, you’re giving
glucocorticoid, you suppress ACTH.
Let’s go one step further.
If you don’t have the ACTH, what then happens
to the adrenals bilaterally?
This is the same analogous pathogenesis of
what you know about with… let’s say you
have a football player taking steroids and
what do you know about that football player
What are you going to recommend or what do
what kind of instructions are you giving this
football player or the patient that you’re
giving this steroids may be?
That he may become infertile.
So, when you’re giving steroids, you then
knock out the anterior pituitary, you don’t
have LH and FSH and therefore, the gonads
are not working properly.
Here, you’re giving or the patient’s taking
glucocorticoids, you knock out the ACTH and
the adrenals aren’t working properly even
though your patient may look like they have
Cushing’s, which they do.
Well, in the inside, you want to be very careful.
So, with all that said, if you stop glucocorticoid
treatment immediately, abruptly, what’s
the most important stress hormone?
If you abruptly stop or cessate your cortisol
administration, your patient’s dead.
Because the adrenals became atrophic over
that long term exogenous steroid administration.
You see how important this is.
So, when you say steroid here, you want to
think of two different administrations from
the adrenal zona glomerulosa or fasciculata
or reticularis or fasciculata, the steroid…
all of those are steroids; cortisol, glucocorticoid
resulting in adrenal insufficiency and do
not forget about the example that I gave you
with testosterone… anabolic steroids.
You see how important that bullet point was
Do not take anything for face value, everything
that I gave you has incredible, incredible