The adrenal cortex produces three major classes of steroids: (1) glucocorticoids, (2) mineralocorticoids, and (3) adrenal androgens. Clinical syndromes may result from deficiency or excess of these hormones. The adrenal medulla produces catecholamines, with excess being caused by a pheochromocytoma (Chap. 119).
HYPERFUNCTION OF THE ADRENAL GLAND
The most common cause of Cushing’s syndrome is iatrogenic, due to administration of glucocorticoids for therapeutic reasons. Endogenous Cushing’s syndrome results from production of excess cortisol (and other steroid hormones) by the adrenal cortex. The major cause is bilateral adrenal hyperplasia secondary to hypersecretion of adrenocorticotropic hormone (ACTH) by the pituitary (Cushing’s disease) or from ectopic sources such as small cell carcinoma of the lung; carcinoids of the bronchus, thymus, gut and ovary, medullary carcinoma of the thyroid; or pheochromocytoma. Adenomas or carcinomas of the adrenal gland account for about 15–20% of endogenous Cushing’s syndrome cases. There is a female preponderance in endogenous Cushing’s syndrome except for the ectopic ACTH syndrome.
Some common manifestations (central obesity, hypertension, osteoporosis, psychological disturbances, acne, hirsutism, amenorrhea, and diabetes mellitus) are relatively nonspecific. More specific findings include easy bruising, purple striae, proximal myopathy, fat deposition in the face and nuchal areas (moon facies and buffalo hump), and rarely androgenization. Thin, fragile skin, and plethoric moon facies also may be found. Hypokalemia and metabolic alkalosis are prominent, particularly with ectopic production of ACTH.
The diagnosis of Cushing’s syndrome requires demonstration of increased cortisol production and abnormal cortisol suppression in response to dexamethasone. For initial screening, measurement of 24-h urinary free cortisol, the 1-mg overnight dexamethasone test (8:00 A.M. plasma cortisol <1.8 µg/dL [50 nmol/L]), or late-night salivary cortisol measurement is appropriate. Repeat testing or performance of more than one screening test may be required. Definitive diagnosis is established in equivocal cases by inadequate suppression of urinary cortisol (<10 µg/d [25 nmol/d]) or plasma cortisol (<5 µg/dL [140 nmol/L]) after 0.5 mg dexamethasone every 6 h for 48 h. Once the diagnosis of Cushing’s syndrome is established, further biochemical testing is required to localize the source. This evaluation is best performed by an experienced endocrinologist. Low levels of plasma ACTH levels suggest an adrenal adenoma, bilateral nodular hyperplasia, or carcinoma; inappropriately normal or high plasma ACTH levels suggest a pituitary or ectopic source. In 95% of ACTH-producing pituitary microadenomas, cortisol production is suppressed by high-dose dexamethasone (2 mg every 6 h for 48 h). MRI of the pituitary should be obtained but may not reveal a microadenoma because these tumors are typically very small. Furthermore, because up to 10% of ectopic sources of ACTH may also suppress after high-dose dexamethasone testing, inferior petrosal sinus sampling may be required to distinguish pituitary from peripheral sources of ACTH. Testing with corticotropin-releasing hormone (CRH) also may be ...