Hyperfunction of the adrenal cortex can cause excess production of mineralocorticoids, glucocorticoids, or androgens. Primary hyperaldosteronism is characterized by autonomous overproduction of aldosterone by the adrenal glands, often leading to hypertension and hypokalemic alkalosis. It can be caused by aldosterone-producing adenomas or bilateral adrenal hyperplasia. Tests like the saline suppression test and adrenal vein sampling are used in the diagnosis. Cushing's syndrome results from prolonged exposure to high levels of cortisol and can be caused by pituitary or adrenal tumors or ectopic ACTH secretion. Signs include central obesity, moon face, and fragile skin

1. Hyperfunction
of
Adrenal Cortex
Hari sharan makaju
M.Sc Clinical biochemistry
PG Resident

2. Adrenocortical Hyperfunction
 Hyper function of the adrenal cortex produces clinical
syndromes of mineralocorticoid excess, glucocorticoid excess,
and androgen excess.
Hyperaldosteronism:
 A medical condition where too much aldosterone is produced
by the adrenal glands, which can lead to sodium retention
and potassium loss.
 Types:
 Primary hyperaldosteronism
 Secondary hyperaldosteronism

3. PRIMARY
HYPERALDOSTERONISM
 Also known as hyporeninemic hyperaldosteronism / Conn’s
Syndrome
 was first described in 1955 by Conn in conjunction with an
aldosterone-producing adrenal adenoma (APA)
 Characterized by autonomous excessive production of
aldosterone by adrenal glands
 Presents with :
hypertension ,
hypokalemic alkalosis
renal K+ wasting

4. PRIMARY
HYPERALDOSTERONISM
Causes:
 Aldosterone-producing adenoma (APA) ≈30% of cases
 Bilateral idiopathic hyperplasia (IHA) ≈60% of cases
 Unilateral (primary) adrenal hyperplasia ≈2% of cases
 Aldosterone-producing adrenocortical carcinoma <1 % of cases
 Familial hyperaldosteronism (FH)
 Glucocorticoid-remediable aldosteronism (FH type I) <1%of cases
 FH type II (APA or IHA) <6% of cases
 FH type III(germline KCNJ5 mutations)—<1% of cases

5. renin-angiotensin system (RAS)
Primary Aldosteronism

6. PRIMARY
HYPERALDOSTERONISM
• Clinical features:
 Hypertension
 aldosterone induced Na retention with increase in Extra
cellular fluid volume
 Muscle weakness and cramping
 Due to decrease K+
 Muscle paralysis:
 severe hypokalemia
 Mild metabolic alkalosis
 Because of increased urinary hydrogen excretion mediated both by
hypokalemia and by the direct stimulatory effect of aldosterone on
distal renal tubule acidification.
 Polydipsia, polyuria and nocturia:
 due to hypokalemia-induced renal concentrating defect

7. PRIMARY
HYPERALDOSTERONISM
Investigation
• Electrolyte & blood gasses:
 Hypernatremia
 Hypokalemia
 Alkalosis
 Random urine potassium greater than 30 mmol/L
 Low renin activity
 Elevated aldosterone concentration
 Plasma aldosterone : renin activity ratio(ARR)
 Sensitive screening test
 Primary hyperaldosteronism(PA) is differentiated from other
hyper mineralocorticoid states
 Most authors recommend an ARR of 20-40, whereas an ARR of at
least 35 has 100% sensitivity and 92.3% specificity in diagnosing PA.

8. Saline Suppression Test
Principle
 Rapid volume expansion with intravenous saline should suppress plasma aldosterone in normal
subjects, but not in patients with primary hyperaldosteronism.
Procedure
 The subject is awakened at 6am and is kept in an upright posture for 2hours.
 Blood is drawn for determination of plasma aldosterone at 8am
 The subject then assumes a supine position, and 2 L of isotonic saline 0.9 g/ dL is infused over a
4 hour period.
 Blood is drawn for plasma aldosterone determination at noon.
Interpretation
 Normal subjects: show a plasma aldosterone concentration of 5 ng/dL (140 pmol/L) or less after
saline infusion.
 Concentrations >10 ng/dL are usually seen in patients with autonomously functioning
aldosterone-secreting tumors.

9. Adrenal venous sampling
 Adrenal venous sampling for aldosterone measurements is used
 to determine whether the right or left adrenal is hypersecreting
aldosterone
 AVS is the criterion standard test to distinguish between unilateral
and bilateral disease in patients with primary aldosteronism
 who want to pursue surgical management for their hypertension.
 Blood is obtained from both adrenal veins and inferior venacava
below the renal veins
 Assayed for aldosterone and cortisol concentrations.
 The sensitivity and specificity of a cortisol corrected plasma
aldosterone cortisol concentration lateralization ratio( ratio of
PAC/cortisol) greater than 4.0 for unilateral disease are 95.2% and
100%,

10. V.-C. Wu et al. Case detection and diagnosis o
primaryaldosteronismeThe consensus of
TaiwanSociety of Aldosteronism: Journal of
Formosan Medical association (2017)116,993-
1005

11. Adrenal vein aldosterone lateralization ratios for patients with unilateral
aldosterone-producing adenomas (APA), bilateral idiopathic hyperplasia
(IHA), and unilateral primary adrenal hyperplasia (PAH)
@Williams Textbook Of Endocrinology,
13th Edition

12. Algorithm provides guidance on when to consider testing for primary aldosteronism

13. Modified from Young WF Jr, Hogan MJ. Renin-independent
hypermineralocorticoidism. Trends Endocrinol Metab. 1994;5:97-106
APA- aldosterone-producing adenoma;
AVS,-adrenal venous sampling;
IHA-idiopathic hyperaldosteronism;
PA-primary aldosteronism;
PAH,-primary adrenal hyperplasia.

14. © 2018 American Heart Association, Inc.
James Brian Byrd. Circulation. Primary Aldosteronism, Volume: 138, Issue: 8, Pages:
823-835, DOI: (10.1161/CIRCULATIONAHA.118.033597)

15. Secondary hyperaldosteronism
 Is increased adrenal production of aldosterone in response to
stimulus outside the adrenal gland activates the renin-angiotensin
system.
 Increase renin secretion
 – hyperreninemic hyperaldosteronism
 Common than primary hyperaldosteronism
 Secondary hyperaldosteronism is suspected in patients
 with volume depletion, edema, and hypokalemic alkalosis.
 Hypertension is usually absent in secondary
hyperaldosteronism
 unless the patient has a renal artery stenosis.

16. Secondary Hyperaldosteronism
Common
 Congestive Heart failure
 Liver cirrhosis
 Nephrotic syndrome
Less common
o Renal artery stenosis
o Sodium – losing
nephritis
o Renin—secreting
tumours

17. Responses of the renin-aldosterone volume control loop
in primary versus secondary aldosteronism
*Initiating event

18. Other Forms of
Mineralocorticoid Excess
Unusual conditions that suggest aldosterone excess but do not
involve disorders of renin, angiotensin II, or aldosterone include
 (1) Apparent Mineralocorticoid Excess,
 (2) Type 1 Pseudohyperaldosteronism (Liddle syndrome),
 (3) Type 2 Pseudohyperaldosteronism, and
 (4) cortisol resistance.

19. Apparent mineralocorticoid
excess (AME)
 Results from 11-beta-hydroxysteroid dehydrogenase-2 (HSD11B2)
deficiency or inhibition.
 Impaired conversion of cortisol to cortisone allows cortisol
to bind to the MR, producing a mineralocorticoid effect
 in the absence of elevations in aldosterone or DOC.
 11-beta-hydroxysteroid dehydrogenase-2 (HSD11B2) deficiency is
described as an “apparent” excess of mineralocorticoid
Because patients can manifest hypertension, hypokalemia,
and alkalosis without elevation of aldosterone nor DOC.
 Apparent mineralocorticoid excess is diagnosed by an increased
ratio of cortisol to cortisone

20. Type 1 pseudohyperaldosteronism
(Liddle syndrome )
 Results from gain-of-function mutations in the beta or gamma
subunit of the amiloride-sensitive Epithelial sodium channel
(ENaC)
 Consequences include
 excessive sodium reabsorption,
 expanded blood volume,
 hypertension,
 hypokalemia,
 alkalosis.
 Because the activity of ENaC is autonomous, both renin and
aldosterone are suppressed.
Type 2 pseudohyperaldosteronism
 is a gain-of- function mutation in the MR

21. Cortisol Resistance
 Loss-of-function mutations in the GR cause cortisol
resistance
 In response to decreased cortisol action, CRH and
ACTH concentrations rise,
 Increasing the circulating cortisol to a sufficient
concentration that functional cortisol deficiency is not
present.
 Protective action of 11-beta-hydroxysteroid dehydrogenase-
2 (HSD11B2) in converting cortisol to cortisone is
overwhelmed,
 resulting in increased binding of cortisol to the MR
and excessive mineralocorticoid effects.

22. Differential diagnosis of hypokalemic, alkalotic hypertension
aldosterone-to-renin ratio >20 to 25

24. CUSHING’S SYNDROME
• Adrenal cortex hyperfunction
• Any condition resulting from overproduction of
cortisol
• Cushing syndrome is caused by
• abnormalities of the pituitary or adrenal gland or may
occur as a consequence of ACTH or CRH secretion by
nonpituitary tumors
• Cushing disease is defined as the specific type of
Cushing syndrome due to excessive pituitary ACTH
secretion from a pituitary tumor.

25. Classification Of Causes of Cushing
Syndrome
Cushing syndrome is most readily classified into
ACTH dependent Causes
 Cushing disease (pituitary-dependent)≈ 70% of cases
 Adenoma (90%)
 Hyperplasia (10 %)
 Ectopic ACTH syndrome ≈ 15% of cases
 Ectopic CRH syndrome
ACTH-independent causes
 Iatrogenic (glucocorticoid, Megestrol acetate)
 Adrenal neoplasm (adenoma, carcinoma) ≈ 5% of cases
 Nodular adrenal hyperplasia
 Primary pigmented nodular adrenal disease (PPNAD)
 Massive macronodular adrenonodular hyperplasia

26. ACTH- dependent

27. ACTH- dependent

28. ACTH-independent

29. Other Syndromes of Hypercortisolemia
When there are clinical and biochemical features of Cushing
syndrome, but when hypercortisolemia is secondary to other factors
it is often referred to as pseudo-Cushing syndrome.
Causes
 Alcoholism
 Abnormalities are all reversible when alcohol abuse by the
patient is stopped.
 Severe depression
 Abnormalities are reversible on correction of the
psychiatric condition.
 Obesity
 Patients with obesity have mildly increased cortisol
secretion rates
 Urinary free cortisol concentrations are either normal or
only slightly elevated

30. Clinical features of Cushing syndrome
(% prevalence).

31. Moon face Truncal obesity
Centripetal obesity with
abdominal striae
Typical bruising and thin skin

32. @Williams Textbook Of Endocrinology,
13th Edition

33. Diagnosis
Routine Laboratory Analysis
 Although there are no routine laboratory investigations specific
to CS, each laboratory test may provide some clue with regard
to the diagnosis, including findings such as:
 Increased neutrophil
 Decreased lymphocyte and eosinophil counts
 Hypokalemia
 Metabolic alkalosis;
 Hyperglycemia; and
 Hypercholesterolemia,
 Useful for the follow-up of treated patients

34. Diagnosis
 Exclude exogenous steroid use.
 Screening tests:-
 24 hr urinary free cortisol excretion
 Dexamethasone overnight test
 Midnight plasma / Salivary cortisol
 Low dose dexamethasone suppression test
 If test are positive then measure plasma ACTH levels
:-
 ACTH normal/high ACTH dependent Cushing’s
 ACTH low ACTH independent Cushing’s

35. Diagnosis
 ACTH dependent Cushing’s:-
 High dose dexamethasone suppression test
 CRH stimulation test
 MRI pituitary
 ACTH independent Cushing’s:-
 Unenhanced CT adrenals

36. Demonstration of increased cortisol
 Assessment of circadian rhythm in cortisol secretion
 24-Hour urinary free cortisol excretion
 Overnight / low dose dexamethasone suppression test
Assessment of circadian rhythm in cortisol secretion.
 Measure 8 am and 11 pm serum cortisol level
Normal : Serum value than value @ 8 am -3 to 20 µg/dL (80-550
nmol/L) average 10 to 12 µg /dl
@ 4 PM are approximately half of morning values.
@ 10 PM to 2 AM, the plasma cortisol concentrations less than 3 µg
/dL
Cushing’s syndrome : rhythm is loss
Pseudo-Cushing : normal circadian

37. Screening tests
24-Hour urinary free cortisol excretion
 less than 2% of secreted cortisol appears in urine as free
cortisol.
 Diagnostic accuracy is greater than 90%
 In general, a 24 hour urinary free cortisol concentration less
than 50 µg/d
 excludes the diagnosis of Cushing syndrome
Overnight Low dose Dexamethasone suppression test
 Dexamethasone suppresses ACTH and cortisol production in
normal subjects, but not in patients with Cushing syndrome.
 Differentiates those who have Cushing syndrome from those
who do not have.

38. Overnight Low dose Dexamethasone
suppression test
Procedure:
 1 mg of dexamethasone taken orally between 10 pm and 12 am
 Blood drawn at 8am next morning- for determination of serum
cortisol
Interpretation:
 In normal subjects cortisol: < 2µg/dl: excludes cushings
syndrome.
 Most patients with Cushing syndrome do not show adequate
suppression, and 0800 hours cortisol concentrations are
usually 10 μg/dL or greater.

39. Overnight Low dose
Dexamethasone suppression test
 Serum cortisol greater than 2 μg/dL may be seen also in cases of
 stress,
 obesity,
 acute or chronic illness,
 alcohol abuse,
 severe depression,
 pregnancy,
 estrogen therapy,
 failure to take dexamethasone, or treatment with phenytoin or
phenobarbital (which can enhance dexamethasone
metabolism).

40. Differential Diagnosis
Morning Plasma ACTH
 Differentiates ACTH-dependent from
ACTH-independent causes.
 In Cushing disease
 50% of patients have a 9 AM ACTH
level within the normal reference
range (2 to
11 pmol/L [9 to 52 pg/mL]);
 in the remainder- modestly
elevated.
 In the ectopic ACTH syndrome
 ACTH levels are high (usually >20
pmol/L [>90 pg/mL]);
 Overlap values are seen in
Cushing disease in 30% of cases
 In patients with adrenal tumors, plasma
ACTH is invariably undetectable (<1
pmol/L).

41. Differential Diagnosis
High-Dose Dexamethasone Suppression Test
 High doses of dexamethasone usually suppress production of
ACTH by pituitary adenomas (benign tumors), as a result blood
and urine levels of cortisol should fall.
 If the excess ACTH is being produced by a nonpituitary tumor,
cortisol production is less likely to be suppressed.
 High dose DST distinguish those pts with cushing’s disease from
those having ectopic ACTH syndrome/adrenal tumor
Procedure:
 8 mg given at 11.00 pm
 Measure cortisol at 8.00 am next morning
Interpretation:
 If cortisol is suppressed: patients with pituitary ACTH macroadenoma
 No suppression: patients with ectopic ACTH syndrome

42. Differential Diagnosis
CRH stimulation test
 In normal subjects, CRH produces a rise in ACTH and
cortisol of 15% to 20%.
 Plasma ACTH concentrations peak 30 minutes after CRH
injection and serum cortisol peaks at 60 minutes
 In Cushing disease , response is exaggerated
 in which typically an ACTH increase greater than 50% and a
cortisol rise greater than 20% over baseline values are seen.
 Poor responses occur in patients with adrenal tumor and
in most patients with nonendocrine
ACTH-secreting tumor
 Patients with depression and anorexia nervosa usually do
not exhibit an exaggerated ACTH response to CRH
injection

43. Comparison of cortisol and ACTH responses to an intravenous injection of
ovine CRH

44. Differential Diagnosis
Inferior petrosal sinus sampling
 The most definitive means of accurately distinguishing
pituitary from nonpituitary ACTH-dependent Cushing
syndrome
 Cushing syndrome when MRI does not reveal a definite
adenoma
Procedure
 Measurement of ACTH from inferior petrosal venous sinus
specimens before and after CRH stimulation
 Blood samples are collected from both right and lef IPS veins
and from a peripheral vein (e.g., the inferior vena cava)
 at −30, 0, +2, +5, +10, and +30 minutes after intravenous
administration ovine CRH (1 µg/kg body weight) over 20 to
60 seconds.
 The ratio of the IPS concentration to the peripheral venous
concentration of plasma ACTH is used to predict the location of
excess ACTH secretion

45. Anatomy of the venous drainage of the pituitary gland through the inferior
@Williams Textbook Of Endocrinolog
13th Edition

46. Inferior petrosal sinus sampling
Interpretation
 An inferior petrosal sinus to peripheral (IPS-P) ratio greater
than 2.0 is consistent with a pituitary lesion (Cushing
disease)
 as the cause of Cushing syndrome,
 Ratio less than 1.4 to 1.7 supports the diagnosis of an ectopic
ACTH syndrome

49. Alternative diagnostic approach

50. Cushing Disease Ectopic ACTH
Syndrome
Adrenal Tumor
Biochemical evaluation
ACTH Normal-increase Normal – Increase Decrease
UFC response to High
dexamethasome
Usually declines
by >50%
Does not decline
by > 50%
Does not decline
by 50%
Basal and post CRH
ACTH levels
IPS> Peripheral IPS= Peripheral Not performed
Radiological evaluations Ct or MRI
Pituitary Abnormal Normal Normal
Adrenal Normal Normal Abnormal
Other location Normal Abnormal Normal
Differentiating the Causes of
Cushing Syndrome

52. Summary

53. Summary