Let's talk about
We're going to review adrenal excess
and adrenal deficiency.
these manifest as excesses of cortisol
in Cushing syndrome,
excesses of adrenaline
and increased aldosterone in the condition
known as primary aldosteronism.
Deficiency states primarily involve
all three hormones as well as androgens.
This condition is known
as Addison's disease.
Cushing syndrome may present
with a low or normal ACTH
with an elevated
Causes may be iatrogenic in cases
of exogenous steroid use.
This usually is where
a prednisone equivalent
of greater than 10-20 milligrams
per day are used.
This can be administered either
and may even be in the
form of creams
used in the treatment of chronic
Endogenous causes include ACTH dependent
and ACTH independent.
is caused by ACTH-secreting
adrenal adenomas and
Let's go through
to confirm the diagnosis
of Cushing syndrome.
When you clinically suspect
the first step is to exclude
Once that's done, we move on
to initial testing.
These tests could include a 24-hour
urinary free cortisol test,
a late-night salivary
and a 1 milligram dexamethasone
Of these three tests,
the first two,
the 24-hour urine free cortisol and
the late-night salary cortisol tests
needed to be repeated if they're positive
to confirm the diagnosis.
Moving down the algorithm,
if these tests are normal,
On the left side of the algorithm,
if these tests are abnormal,
the next step is to exclude
What is physiological
That's essentially increases
that are caused by psychological stress
or severe illness
and can certainly muddy the picture in the
diagnosis of Cushing syndrome.
But once you have excluded
you then move down to additional testing
which can include imaging.
If the imaging
you've confirmed your diagnosis
of Cushing syndrome.
If however it's normal,
repeating the initial test
to confirm that they were indeed positive
is probably the next step.
If these are normal, then crushing
syndrome is unlikely.
The treatment of
consists of the surgical removal of the
adrenal gland or the pituitary mass
or the ectopic tumor
that is producing ACTH.
Bisphosphonates for low bone density
are a good idea
because long-term cortisol would have
invariably led to osteoporosis.