ADRENAL GLAND

Bardelosa, Jesse Gale M.

Barretto, Alyssa Nicole
3MT1
Catecholamine Test
 ● clinical laboratory
measurements are
Catecholamine primarily directed at the
diagnosis of
Test neuroendocrine tumors
● Measured through 24-
hour period urine or
blood extraction
● Fasting: 12 hours
 Pheochromocytoma-paraganglioma
(PPGL)
● Pheochromocytoma – rare tumor arising from the chromaffin
cells

● Paraganglioma – arise from the sympathetic ganglia. (Extra-

adrenal pheochromocytoma)

Symptoms- Palpitations, Headaches, Sweating

Catecholamine Test
● Catecholamine in urine samples:

○ best preserved with hydrochloric acid to maintain urine

acid

● For storage over protracted periods of time, aliquots are best

kept frozen at -80°C

● In blood specimens:

○ best collected into tubes containing heparin or

ethylenediaminetetraacetic acid (EDTA)

○ stored on ice before centrifugation at 4C

Catecholamine Test: Reference values
Blood
● Dopamine:

■ Less than 30 pg/ml with no change in posture

● Epinephrine

■ Lying down: undetectable up to 110 pg/ml

■ Standing: undetectable up to 140 pg/ml

● Norepinephrine

■ Lying down: 70-750 pg/ml

■ Standing: 200-1700pg/ml
Catecholamine Test: Reference values
Urine ■ 4 to 9 years: 0.2 to 10.0
● Dopamine mcg/ 24 hours

■ Younger than 1 year: 0.0 ■ 16 years or older 0.0 to

to 85.0 mcg/ 24 hours 20.0 mcg/ 24 hours
● Norepinephrine
■ 2 to 3 years: 40.0 to
260.0 mcg/ 24 hours ■ Younger than 1 year: 0.0
tp 10.0 mcg/24 hours
■ 4 years or older: 65.0 to
400.0 mcg/24 hours ■ 7 to 9 years: 13.0 to 65.0
● Epinephrine mcg/24 hours

■ Younger than 1 year: 0.0 ■ 10 years or older: 15.0 –

to 2.5 mcg/ 24 hours 80.0 mcg/ 24 hours
 ● Normetanephrine –
screening for
Pheochromocytoma
● Metanephrine – screening
Homovanillic acid, for Pheochromocytoma
and Paraganglioma
Metanephrine, ● Homovanillic acid-
Normetanephrine, screening for
Vanillymandelic acid Neuroblastoma
● Vanillymandelic acid –
screening for
Neuroblastoma
Homovanillic acid, Metanephrine, Normetanephrine,
Vanillymandelic acid: TESTS

● Plasma levels
o Fasting for 6-12 hours

o Patient should be in supine position prior to blood

sampling

o Collect sample.

o Analyzed using High-Performance Liquid Chromatography

with Tandem Mass Spectromethry (HPLC-MS/MS)

o Normal levels vary from lab to lab:

Reference values:
Reference values:

● Normetanephrine <112 ng/L (0.6 mmol/L)

● Metanephrine <61 ng/L (0.31 mmol/L)
= exclude pheochromocytoma

● Normetanephrine >400 ng/L (2.19 mmol/L)

● Metanephrine >236 ng/L (1.20 mmol/L)
=high probability of pheochromocytoma
Homovanillic acid, Metanephrine, Normetanephrine,
Vanillymandelic acid: TESTS

● 24-hour Urine Test

○ 24 hour urine sample collected in a 3 liter bottle

■ Discard first urine in the morning then collect all urine for the next
24 hours

○ Analyzed using High-Performance Liquid Chromatography with

Tandem Mass Spectroscopy (HPLC-MS/MS)

○ Urinary VMA has poor sensitivity and specificity.

 Normal Values may vary
● Metanephrine: 24 to 96 mcg/24 hours (some laboratories give the range
as 140 to 785 mcg/24 hours)
● Normetanephrine: 75 to 375 mcg/24 hours
● Homovanillic acid: 0.0-15.0 mg/24 hours
● VMA: 2 to 7 milligrams (mg)/24 hours (10.09 mcmol/24 hours)
 ● Ultraviolet
spectrophotometry which is

Pisano Method used in the

spectrophotometric assay of
metanephrines in diagnosing
excess catecholamine in urine
Pisano Method
● 24 hour urine/ random specimen
● Proper specimen collection must be observed and the sample container
must be light and opaque and must contain 10 mL if 6N HCL for
preservation of catecholamine metabolites
● Specimens for assays can be frozen until is ready for testing

● The spectrophotometric assay for the metanephrines is performed by

extraction and then subsequent oxidation of the compounds to form
vanillin which can be measured by ultraviolet spectrophotometry
 ● Epinephrine stimulates glycogen
breakdown (glycogenolysis) and
decreases glucose use, thereby
increasing blood glucose
concentrations.

○ Stimulates glucagon secretion

and inhibits insulin secretion
by the pancreas thus further
Glucagon increasing blood glucose.

Stimulation ○ pheochromocytomas, secrete

excess epinephrine or
norepinephrine and produce
moderate hyperglycemia as
long as glycogen stores are
available in the liver.
Glucagon Stimulation
● The glucagon stimulation test can lead to dangerous rises in blood
pressure and is rarely used
● should be performed only in patients whose blood pressure is well
controlled, and a physician must be present throughout the test.

● REFERENCE VALUE:

○ A rise in plasma norepinephrine to greater than threefold, or

greater than 2000 pg/mL = Pheochromocytoma

● The proposed mechanism of action is stimulation of glucagon-

sensitive adenylate cyclase receptors expressed on these tumors.
 ● Clonidine - an anti-
hypertensive agent,
suppresses central
Clonidine sympathetic outflow.
Supression Test ● May be useful for further
confirming or excluding a
pheochromocytoma
Clonidine Suppression Test
 Clonidine suppression test (92% accurate) determines if excess
catecholamine production is suppressible.

● After stopping antihypertensive drugs for at least 12 hours, total plasma

catecholamines are measured.
● Clonidine (0.3 mg) is administered and repeat plasma catecholamine
levels are obtained 3 hours later.

○ Patients without pheochromocytoma will have a fall in plasma total

catecholamines greater than 500 pg/mL (this is inaccurate in patients
with normal catecholamine levels)
 ● Test for Chromogranin A
which is a neuroendocrine cell
that is also secreted along with
catecholamins

● Elevated Chromogranin A has

Chromogranin been documented in patients
with Pheochromocytoma
A (80%) but still not specific

● it has poor diagnostic

specificity.

○ Due to even mild degrees of

renal impairment (e.g.,
creatinine clearance [CrCl]
<80 mg/mL/min) can lead to
significant increases in serum
concentration of CgA
Chromogranin A
• Its major use is in postoperative monitoring for recurrence of these
tumors.

● For 24-hour urine collections, creatinine is measured to verify the

adequacy of the collection
○ For urine preservation - should be collected in a container with 25 mL of 6 NHCl.

○ Analyze using High-Performance Liquid Chromatography with Tandem Mass

Spectroscopy (HPLC-MS/MS
Chromogranin A
● Serum chromogranin A is not routinely measured

○ Less sensitive

○ Less specific for pheochromo-cytoma than are direct catecholamine

and metabolite measurements.
● In combination, serum chromogranin A and plasma catecholamines are
specific (95%) but less sensitive (88%)
● If GFR = < 80mL/min - test sensitivity drops to 70%
● If Combined:

○ resting plasma catecholamines = >200 pg/mL

○ Chromogranin A = >20 pg/mL

= positive predictive value of 97% when glomerular filtration rate is

normal
Chromogranin A
● Plasma Cathecolamines

○ Fasting overnight

○ Patient placed in a reclining position in a quiet environment with a

heparin lock inserted intravenously

○ Collect blood after 20-30 minutes and place sample in a prechilled

EDTA tube

○ Sample should be kept in ice water (4 degrees)

○ Until centrifuged
 ● Aldosterone assays are
performed on plasma using
extraction to remove

Aldosterone aldosterone from plasma

proteins, followed by

Assay chromatography and

immunoassay or, preferably,
LC-MS/MS.

● Urine is assayed following acid

hydrolysis and extraction.

● Normative values exist for

different age groups, postures,
and sodium intakes

● HPLC with tandem mass

spectrometry affords greater
consistency and is gradually
 Aldosterone Assay
● Useful in detecting a condition called aldosteronism
● caused by excess secretion of the hormone from the adrenal glands. 

● There are two types of aldosteronism:
○ Primary
○ Secondary 

● Primary aldosteronism
○ most commonly caused by an adrenal tumor, as in Conn’s syndrome. Idiopathic (of unknown
cause)
○ hyperaldosteronism is another type of primary aldosteronism.

●  Secondary aldosteronism 

○ More common

○ May occur with congestive heart failure, cirrhosis with fluid in the  abdominal

cavity (ascites), certain kidney diseases, excess potassium, sodium-
depleted diet, and toxemia of pregnancy.
 Reference Value
● Normal results are laboratory-
specific and also vary with sodium intake, 
with time of day, source of specimen age, sex, and posture.

● Reference ranges for blood include:
○ supine (lying down): 3-10 ng/dL
○ upright (sitting for at least two hours): Female: 5-
30ng/dL; Male: 6-22 ng/dL.
○ Reference ranges for urine: 2-80 mg/24 hr.
Renin
 Renin
● Renin measurements are of two types: PRA and PRC.

● The PRA is a bioassay wherein a plasma specimen containing renin is allowed

to react with its substrate, angiotensinogen; after a specified period of time,
the reaction is terminated, and generated angiotensin I is measured by RIA.

○ This type of assay is the most widely used method for the determination of renin

○ Comparison of results among laboratories is not possible because of pro- cedural

differences:

■ Such as variations in pH, ionic strength, length of the assay, the

angiotensinase inhibitor, the conditions under which the speci- men was
obtained, and because of the lack of a specific reference prepara- tion.

● The PRC assay is an immunoassay directed to the renin molecule itself

● PRC remains within the reference interval, whereas PRA increases owing to the
increase in substrate
 Renin
 Specimen processing:

○ Blood should be drawn into an iced EDTA tube, which inactivates the
enzymes (e.g., angiotensinases)

○ centrifuged at 4° C

○ the plasma should be separated promptly from the cells

○ frozen immediately, and kept frozen until ready to be analyzed

○ the specimen is stable for several months at −20° C

● Normal values range from 1.9 to 3.7 ng/ml/hour. Normal value ranges
may vary slightly among different laboratories. Note: ng/ml/hour =
nanograms per milliliter per hour
 Normal Values
● Normal values range from 1.9 to 3.7 ng/ml/hour. Normal value ranges
may vary slightly among different laboratories. Note: ng/ml/hour =
nanograms per milliliter per hour
 ORAL SODIUM
LOADING,
SALINE
INFUSION,
FLUDROCORTIS
ONE ● All of which are
SUPPRESSION mineralocorticoid
suppression tests.
AND CAPTOPRIL
● Confirmatory tests for
CHALLENGE primary hyperaldosteronism.
TESTS
Oral Sodium Loading Test
● A cumbersome suppression test, but is at present rarely
used in expert centers.

PROTOCOL:
● A daily ingestion of a high sodium diet (at least 10-12 g of
sodium chloride) for at least 3 days before the test is
performed.
● Followed by 24-hour urine measurements of aldosterone,
potassium, sodium and creatinine excretions. (creatinine
measurement validates adequacy of urine sample
collection.
Oral Sodium Loading Test

● 24-hour sodium value of more than 200 mEq/day confirms

adequate salt load during the days prior to the test. (for
validity of the measurements)
● Urinary aldosterone concentration:
○ Normal response: <10 ug/24 h (28 nmol/24 h)
○ (+) Result: >12 or 14 ug/24 h (33 or 39 nmol/24 h) =
Primary hyperaldosteronism [PA] (excessive production
of aldosteronism)
● Should be avoided particularly in cases of heart failure or
serious cardiac arrhythmia.
Saline Infusion Test
● Suppression test widely used internationally
● Suppresses the plasma renin activity, which then ultimately
suppress the aldosterone secretion

PROTOCOL:
● Patient should remain in a supine position, or alternatively
in a seated position for 30-60 minutes before and during
the test.
● 2 L of isotonic saline solution (0.9% salt solution) is infused
through an IV for 4 hours, from 8 am - 9 am.
○ *alternative: administration of 10 12 mg NaCl tablets
daily for 3 days
Saline Infusion Test

● Blood samples are drawn at time 0 and 4 hours for plasma

aldosterone, cortisol and renin measurements, with blood
BP and heart rate monitored.
○ Normal response: < 5 ng/dL PAC
○ (+) Result: >10 ng/dL PAC = PA
○ Borderline and considered to be inconclusive: 5-10
ng/dL PAC
Fludrocortisone Suppression Test

● Fludrocortisone is a synthetic mineralocorticoid that

produces a comparable suppression of aldosterone
secretion.
● It requires hospitalization of the patient and 4-5 days to
complete.
Fludrocortisone Suppression Test

PROTOCOL:
● Oral administration of 0.1-0.2 mg every 6 hours for over 4
days.
○ Supplemental sodium chloride is given every 6 hours to
maintain 24-hour urine sodium content with a level
greater than 200 mEq/day; as well as potassium
supplementation of every 6 hours to maintain plasma
potassium level.
Fludrocortisone Suppression Test

● Blood pressure and serum potassium levels must be

monitored daily
● After 4 days of loading, plasma aldosterone concentration
(PAC) is measured.
○ Normal response: < 8 ng/dL PAC; < 12 mcg/day U-Aldo
○ (+) result: > 8 ng/dL PAC; > 12 mcg/day U-Aldo
Captopril Challenge Test
● This test is recommended when risks from volume overload
preclude the use of other procedures.
● Makes use of Captopril, an ACE inhibitor, that inhibits
conversion of angiotensin I to angiotensin II stimulus to
aldosterone secretion.
Captopril Challenge Test
PROTOCOL:
● An oral intake of 25-50 mg captopril after sitting for at least
1 hour.
● Blood sampling for PAC, PRA and plasma cortisol at time 0
and 2 hours after.
○ Normal Response: 30% > is suppressed
○ Primary hyperaldosteronism:
■ Aldosterone-renin ratio (ARR): <30%-50%
■ Plasma aldosterone remains elevated (≥8.5 ng/dL)
■ Cutoff thresholds: 8.5 - 13.9 ng/dL
■ Renin remains suppressed
 CRH STIMULATION, ACTH
STIMULATION, ACTH TEST,
CORTISOL TEST
CRH Stimulation Test

● Confirmatory test for cushing’s syndrome

● The use of this test is in the differential diagnosis of
adrenocortical hyperfunction and hypofunction.
● Also used in the differential diagnosis of endogenous
Cushing syndrome and to distinguish secondary from
tertiary ACTH deficiency.
● CRH is a naturally-occurring hormone which causes the
pituitary gland to secrete the hormone ACTH. (which makes
the adrenal gland produce cortisol)
● CRH stimulation test measures the level of cortisol in the
blood before and after being given a synthetic form of CRH.
CRH Stimulation Test

PROTOCOL:
● Patient should fast for at least 4 hours prior testing
● Synthetic ovine CRH at 1.0 ug/kg body weight is injected as
an intravenous bolus over 30 seconds.
● Blood for specimens is collected at 15 minutes and 1
minute before CRH administration and at 30, 45, 60, 90, and
120 minutes after CRH administration for measuring
corticotropin and cortisol levels
CRH Stimulation Test

○ Note that if only plasma ACTH is measured in Cushing

syndrome, 5- and 0-minute samples prior to and 15-
and 30-minute samples after CRH administration are
sufficient. If only serum cortisol level is measured,
samples at 5 and 0 minutes prior to and 15 and 30
minutes after CRH administration are again sufficient.
○ Specimen: Plasma, frozen
○ Volume: 0.3 - 0.8 ml
○ Container: Plastic or siliconized glass lavender-top EDTA
CRH Stimulation Test
Diagnosis Corticotropin Response Cortisol Response
Pituitary Cushing syndrome Normal or increased Normal or increased

Adrenal Cushing syndrome Suppressed Suppressed

Ectopic Cushing syndrome Suppressed Suppressed

CRH Stimulation Test
DIAGNOSIS CORTICOTROPIN CORTISOL
RESPONSE RESPONSE
Pseudo-Cushing syndrome Suppressed Suppressed

Pituitary Adrenal insufficiency Suppressed Suppressed

Hypothalamic adrenal insufficiency Normal Low

ACTH Stimulation Test

● Screening test for for Primary adrenal insufficiency

(Addison’s disease)
● Also known as Cosyntropin stimulation test, which is
designed to document the functional capacity of the
adrenal glands to synthesize cortisol.
○ Cosyntropin is is a synthetic cortisol and aldosterone
stimulator
● It measures how well the adrenal glands respond to
adrenocorticotropic hormone (ACTH).
● It differentiates secondary adrenal insufficiency (decrease
or no ACTH response) from tertiary adrenal insufficiency
(increased ACTH response)
ACTH Stimulation Test
PROTOCOL
● Blood is drawn for an initial baseline level (can be drawn
anytime of the day),
● 250 ug of Cosyntropin (synthetic ACTH) is injected IM or IV
● Blood is drawn after 30 minutes and/or 60 minutes
● Normal Response: cortisol level >18-20 ug/dL (500-550
nmol/L)
○ Serum ACTH level at baseline may help differentiate the
following:
■ primary adrenal insufficiency = elevated ACTH >50-
100 pg/ml
■ secondary or tertiary = low ACTH level <10 pg/ml
● Failure of aldosterone to increase by more than 4 ng/dL
over baseline suggests primary adrenal dysfunction
ACTH Test
● Used to diagnose excessive cortisol secretion from the
adrenal gland.
● Measures the levels of both ACTH and cortisol in the blood.

PROTOCOL:
● Fasting overnight before taking the test
● Test is done in the morning
● Blood is drawn and is used to test ACTH levels
○ Normal response: Adults: 10-50 pg/ml at 8AM and drops
to below 5-10 pg/ml at midnight
○ Measuring both ACTH and cortisol can help to
differentiate among some of these conditions because
the level of ACTH normally changes in the opposite
direction to the level of cortisol.
Cortisol Test

● This test is used to check if cortisol production is in excess

or deficient. (Cushing’s syndrome and Addison’s disease)
● Used to diagnose the diseases and a way to assess the
function of the adrenal gland and pituitary glands.

PROTOCOL:
● Blood Test:
○ Specimen: Serum (red top)
○ Usually done twice: one in the morning (high levels
from 8 AM - 10 AM) and again at around 4 pm (low level
but lowest levels from 10 PM-12 MN)
○ Normal Range: 6 - 23 mcg/dL
Cortisol Test

● Urine Test:
○ Use a 24-hour urine sample.
○ Normal Response:
■ Morning – 7-28 ug/dl
■ Afternoon – 2-18 ug/dl
● Saliva Test:
○ usually done late at night
○ patient given a test kit
○ collect samples between 11 PM- 12MN
○ screening test for Cushing’s syndrome - midnight salivary
cortisol test (high saliva cortisol)
Cortisol Test

○ Normal Range:
■ 7 a.m.-9 a.m.: 100-750 ng/dL
■ 3 p.m.-5 p.m.: <401 ng/dL
■ 11 p.m.-midnight: <100 ng/dL
PORTER SILBER REACTION
Porter Silber Reaction

○ It is the basis of the 17-hydroxycorticosteroid test.

○ A reaction, visible as a change in color to yellow, that
indicates the amount of adrenal steroids excreted per
day in the urine.
○ Used to evaluate adrenocortical function.
○ A rearrangement of dihydroxyacetone grouping
precedes condensation with phenylhydrazine yield the
final yellow product.
 1. Low-dose Overnight

DEXAMETHA Dexamethasone
Suppression Test
2. Standard Low-dose
SONE Dexamethasone
Suppression Test
SUPPRESSIO 3. Overnight High-dose
Dexamethasone
N TEST Suppression Test
4. Standard High-dose
Dexamethasone
Suppression Test
Dexamethasone Suppression Test

● Dexamethasone is an exogenous steroid that provides a

negative feedback mechanism to the pituitary gland.
● It is a synthetic glucocorticoid that does not interact with
cortisol measurement.
● The test measures whether ACTH secretion can be
suppressed.
● 2 types of dexamethasone suppression tests: low dose and
high dose. Both can be done overnight and standard (2-3 days).

Reference Range: 1.8 mcg/dl (<50 nmol/l)

 LOW-DOSE
● Suppression is absent
DEXAMETHAS in patients with
ONE Cushing syndrome, but
present in normal
SUPPRESSION healthy patients.
TEST ● It suppresses
CORTISOL.
Low-dose Overnight Dexamethasone
Suppression Test
○ Screening test for cushing’s syndrome

PROTOCOL:
○ 1 mg of dexamethasone is orally taken between 11 PM -
12 MN
○ Blood is collected the following day 8 AM - 9 AM, urine
may be tested for 17-OHCS
■ Normal result: cortisol value < 5.0 ug/dl; 17-OHCS of
<4 mg/g creatinine after the test.
■ (+) result: cortisol level not suppressed (>5.0 ug/dl)
● 17-OHCS => 4 mg/g creatinine
Standard Low-dose Dexamethasone
Suppression Test
○ Confirmatory test for cushing’s syndrome

PROTOCOL:
○ 0.5 mg oral dexamethasone is given every 6 hours for 2
days, followed by IV CRH (1ug/kg) 2 hours after last dose
of dexamethasone; (9 AM 3 PM, 9 AM 3 PM)
○ Cortisol is measured 6 hours after last dose.
○ 24-hour urine and serum samples are also collected as
specimens.
○ (+) result: elevated serum cortisol level.
 False-positive results in cases
such as:
LOW-DOSE ● oral contraceptive pills
● drugs such as:
DEXAMETHAS ○ Phenytoin
○ Phenobarbital
ONE ○ Carbamazepine
○ Rifampicin
SUPPRESSION
False-negative results in cases
TEST such as:
● nephrotic syndrome
● ritonavir
● fluoxetine
● liver failure
 HIGH-DOSE ● exerts negative feedback on
pituitary ACTH secretion by
DEXAMETHAS acting on cells secreting ACTH
and not the cells or adrenal or
ONE ectopic production of ACTH.
● Suppression is absent in
SUPPRESSION patients with Cushing syndrome
due to ectopic ACTH secretion or
TEST adrenal abnormalities.
● Used in patients with confirmed
Cushing syndrome when further
workup is needed to identify the
etiology.
Overnight High-dose Dexamethasone
Suppression Test
PROTOCOL:

○ Serum cortisol is checked at baseline.

○ 8 mg of dexamethasone is administered orally between
11 PM and 12 MN.
○ Cortisol is measured between 8 AM and 9 AM the next
morning.
Standard High-dose Dexamethasone
Suppression Test
PROTOCOL:

○ Serum cortisol level and/ or 24-hour urinary free

cortisol is measured as a baseline.
○ 2mg of dexamethasone is orally administered every. 6
hours for 2 days.
○ urine for free cortisol is collected during the test and
serum cortisol is checked 6 hours after the last dose.
 (+) results:
● Cushing's disease with an
ACTH producing pituitary
adenoma, high dose
DEXAMETHA dexamethasone is enough
to suppress the anterior
SONE pituitary production of
ACTH.
SUPPRESSIO ● Cortisol secreting adrenal
tumor, high levels of
N TEST cortisol and low levels of
ACTH.
● Ectopic ACTH production,
high ACTH and high cortisol
- paraneoplastic cushing
syndrome.
METYRAPONE TEST
Metyrapone Test

● A stimulation test
● Metyrapone is an inhibitor of the enzyme 11 B-hydroxylase that
converts 11-deoxycortisol to cortisol.
● Measures the ability of the pituitary gland to respond to
declining levels of circulating cortisol, thereby secrete ACTH.
● Used to evaluate the pituitary gland’s ability to produce ACTH in
response to a decreased cortisol level.
● It is used as an alternative diagnostic or confirmatory test for
secondary or tertiary adrenal insufficiency.
● It is performed only if the ACTH stimulation test gives normal
results.
Metyrapone Test

PROTOCOL:
○ Oral dose: 30 mg of metyrapone is given at midnight (or 11
pm)
○ Blood collection: blood is collected the following morning at
8 am.
○ Normal response: elevated plasma 11-deoxycortisol >7
ug/dL (200 nmol/L)
○ (+) Result: serum 11-deoxycortisol less than 7 ug/dL and
cortisol less than 5 ug/dL

● Failure of cortisol to fall invalidates the test

● Not routinely used, although maybe better than High dose DST
 1. Dopamine β Hydroxylase
Deficiency and other
adrenal medullary enzyme

DISEASE deficiencies
2. Pheochromocytoma,
CORRELATIO Neuroblastoma,
Ganglioneuroma, White
NS Coat Hypertension
3. 21 Hydroxylase and Other
Adrenal Cortical Enzyme
Deficiencies
4. Adrenal Insufficiency and
Excess
5. Cushing’s Syndrome
 Dopamine β
Hydroxylase
1. Dopamine β Hydroxylase
Deficiency and Deficiency
other adrenal
medullary enzyme
deficiencies
Dopamine β Hydroxylase Deficiency and
other medullary enzymes deficiencies
● Dopamine beta-hydroxylase (DβH) deficiency is a very rare form of primary
autonomic failure characterized by a complete absence of noradrenaline
and adrenaline in plasma together with increased dopamine plasma levels

● HVA levels may also be altered in disorders of catecholamine metabolism;

monoamine oxidase-A deficiency can cause decreased urinary HVA values,
while a deficiency of dopamine beta-hydrolase (the enzyme that converts
dopamine to norepinephrine) can cause elevated urinary HVA values.

● Decreased urinary HVA values may suggest monoamine oxidase-A

deficiency.
 Pheochromocytoma,
Neuroblastoma,
Ganglioneuroma, White
Coat Hypertension
Pheochromocytoma

Pheochromocytomas

○ Composed to chromaffin cells which synthesize catecholamines

■ rare catecholamine-producing tumors

■ Approximately 90% of tumors arise within the adrenal

medulla, and 10%–15% are of extraadrenal origin

● Normetanephrine >400 ng/L (2.19 mmol/L)

● Metanephrine >236 ng/L (1.20 mmol/L)
=high probability of pheochromocytoma
Ganglineuroma
● Ganglioneuroma is a rare and benign tumor of the autonomic nerve
fibers arising from neural crest sympathogonia, which are completely
undifferentiated cells of the sympathetic nervous system.
● Blood and urine tests may be done to determine if the tumor is producing
hormones or other chemicals.
○ Metanephrine: 24 to 96 mcg/24 hours (some laboratories give the range as 140 to 785
mcg/24 hours)

○ Normetanephrine: 75 to 375 mcg/24 hours

○ Homovanillic acid: 0.0-15.0 mg/24 hours

○ VMA: 2 to 7 milligrams (mg)/24 hours (10.09 mcmol/24 hours)

Neuroblastoma
● neural crest origin, arising within the adrenals or the sympathetic chain.
● Symptoms relate primarily to tumor mass rather than to hypertension,
which is often mild or absent

● Homovanillic acid- screening for Neuroblastoma

● Vanillymandelic acid – screening for Neuroblastoma

● Elevated urinary excretion of

HVA and VMA is the result of excess tumor production of dopamine and
norepinephrine, respectively.
White coat hypertension
● This form of labile hypertension
● Labile hypertension and paroxysmal hypertension are both conditions
where blood pressure fluctuates widely between normal and high levels.
● Paroxysmal hypertension is sometimes considered a type of labile high
blood pressure, but there are a few key differences between the two
conditions:

● A small percentage, less than 2 out of 100, of paroxysmal hypertension

cases are caused by a tumor in the adrenal glands. This tumor is known
as a pheochromocytoma.
21
HYDROXYLASE
AND OTHER
ADRENAL 1. 21-hydroxylase deficiency
2. 11 6-hydroxylase deficiency
CORTICAL 3. 36-hydroxysteroid
dehydrogenase-isomerase
ENZYME deficiency
4. 17-hydroxylase deficiency
DEFICIENCIES
21-hydroxylase deficiency
● is the most common form of Congenital Adrenal
Hyperplasia. (CAH)
● It leads to hirsutism in women and other symptoms caused
by excess androgen levels such as virilization; infertility and
amenorrhea.
● diagnosis is made by measuring the level of 17-OHP in
amniotic fluid (by PCR) or by genotyping cells (by Southern
blotting) obtained by chorionic villous sampling.
21-hydroxylase deficiency
● definitive method: genotyping
● common method for detection: ACTH stimulation and 17 a-
hydroxyprogesterone tests.
● lab findings: elevated plasma levels of 17 a-
hydroxyprogesterone and pregnanetriol; increased urinary
pregnanetriol and 17-KS
● definitive gene: CYP21
11 6-hydroxylase deficiency
● is the 2nd most common form of CAH.
● it is associated with virilization and hypertension
● lab findings: increased serum deoxycortisol, and urinary 17-
OHCS and 17-KS.
● definitive gene: CYP11B1
36-hydroxysteroid dehydrogenase-isomerase
deficiency
● It results in an elevated ratio of 17-a-hydroxypregnenolone
to 17-a-hydroxyprogesterone and increased ratio of DHEA
to androstenedione.
● It is characterized by pseudohermaphroditism in female
infants, incomplete masculinization in male infants.
● lab findings: elevated serum 17-hydroxypregnenolone,
pregnenolone and DHEA; increased urinary 17-KS.
● defective gene: HSD3B2
17-hydroxylase deficiency
● It is characterized by the inability to convert 17-
hydroxypregnenolone to DHEA and 17-a-
hydroxyprogesterone to androstenedione.
● it will result in decreased androgen, cortisol and estrogen
synthesis; decrease progesterone synthesis.
● indicators: amenorrhea, defective ovarian maturation,
pseudohermaphroditism in males; hypertension and
hypokalemic alkalosis.
● lab findings: increased serum deoxycortisol
● defective gene: CYP17
 Adrenal Insufficiency

ADRENAL 1. Primary Adrenal Insufficiency

2. Secondary Adrenal
INSUFFICIENC Insufficiency

Adrenal Excess
Y AND EXCESS
3. Cushing’s Syndrome
Primary Adrenal Insufficiency

○ It is due to decreased cortisol production - 90%

destruction of the adrenal cortex; aldosterone
deficiency; excess ACTH release.
○ Disorder: Addison’s disease (hypotension,
hyponatremia, hyperkalemia, weight loss,
hyperpigmentation)
○ Addison’s disease is due to autoimmune adrenalitis,
tuberculosis, hemorrhage, HIV-AIDS infection.
○ Screening test: ACTH stimulation test (low cortisol,
aldosterone and renin; high ACTH)
Secondary Adrenal Insufficiency

○ is due to hypothalamic-pituitary insufficiency with loss

of ACTH.
○ No problem with mineralocorticoid secretion; absence
of hyperpigmentation.
○ Screening test: ACTH Stimulation Test (delayed response-
low cortisol and ACTH)
Cushing’s Syndrome

● Metabolic disorder resulting from chronic excessive production

of cortisol by the adrenal cortex or by the administration of
large doses of glucocorticoids.
● Also represents a failure in the body’s ability to regulate the
secretion of cortisol or ACTH.
● Most common cause of the syndrome is a pituitary tumor that
causes an increased secretion of ACTH.
REFERENCES
ACTH Stimulation Test. (2020, April 1). Retrieved April 4 from https://labtestsonline.org/tests/acth-stimulation-test

Chrousos, G. P. (2018, October 19). How is a saline infusion test performed in the workup of hyperaldosteronism? Retrieved April 1, 2020, from
https://www.medscape.com/answers/920713-68766/how-is-a-saline-infusion-test-performed-in-the-workup-of-hyperaldosteronism#qna

Corticotropin-releasing Hormone Stimulation. Retrieved April 3, 2020 from https://www.labcorp.com/resource/corticotropin-releasing-hormone-stimulation

CRH Stimulation. Retrieved April 3, 2020 from https://www.dartmouth-hitchcock.org/endo/crh_stimulation.html

Elhomsy, G. (2019, November 19). Dexamethasone Suppression Test Retrieved April 4 from https://emedicine.medscape.com/article/2114191-overview

Huizen, J. (2019, February 27). What to know about 24-hour cortisol urine tests. Retrieved April 4 from https://www.medicalnewstoday.com/articles/324573

Holm, G. (2016, October 26). ACTH (Cosyntropin) Stimulation Test. Retrieved April 4 from
https://www.healthline.com/health/acth-cosyntropin-stimulation-test

Luo, E. (2017, June 23). Cortisol Level Test. Retrieved April 2 from https://www.healthline.com/health/cortisol-urine

Metyrapone Stimulation. (n.d.). Retrieved April 4 from https://www.labcorp.com/resource/metyrapone-stimulation

Morera, J., & Reznik, Y. (2019, February). MANAGEMENT OF ENDOCRINE DISEASE: The role of confirmatory tests in the diagnosis of primary aldosteronism.
Retrieved April 3, 2020 from https://eje.bioscientifica.com/view/journals/eje/180/2/EJE-18-0704.xml

Uwaifo, G. I. (2020, March 24). How is the fludrocortisone suppression test used to confirm primary aldosteronism? Retrieved April 1, 2020, from
https://www.medscape.com/answers/127080-90531/how-is-the-fludrocortisone-suppression-test-performed-in-the-workup-of-primary-aldosteronism

Uwaifo, G. I. (2020, March 24). How is the salt-loading test used to confirm primary aldosteronism? Retrieved April 1, 2020, from
https://www.medscape.com/answers/127080-90508/how-is-the-salt-loading-test-used-to-confirm-primary-aldosteronism#qna

What Is an ACTH Test?. (n.d.). Retrieved April 4 from https://www.webmd.com/a-to-z-guides/acth-test#2