PA31.8-10 | Adrenal Gland Disorders — Summary & Reflection

REFLECT

You have now worked through the entire adrenal pathology spectrum. Before you close this SDL, pause for a moment and answer these questions in your own words (you do not need to write them down — just reason through them):

1. You are shown two adrenal glands at autopsy — both are massively enlarged and haemorrhagic. The patient was a 19-year-old who died within 24 hours of admission with a petechial rash. What is the diagnosis, and what was the precipitant?

1. A patient has elevated cortisol that does not suppress on high-dose dexamethasone, and their plasma ACTH is very elevated. Where is the source — pituitary, adrenal tumour, or elsewhere? Why?

1. A 4-year-old boy has an adrenal mass, periorbital ecchymoses, and elevated urinary HVA. You see Homer-Wright rosettes on biopsy. Which molecular marker will most powerfully predict his prognosis?

If you were uncertain on any of these, review the relevant section once more. The ability to reason from morphology to mechanism to management is what distinguishes a clinician from a memoriser.

KEY TAKEAWAYS

Adrenal Gland Disorders — Key Points for Exam Revision

Cushing Syndrome:
• Commonest cause overall = exogenous steroids (iatrogenic).
• Commonest endogenous cause = pituitary ACTH-secreting adenoma (Cushing disease).
• High-dose DST suppresses cortisol in pituitary disease but NOT in ectopic ACTH or adrenal tumour.
• Morphology: bilateral hyperplasia (pituitary/ectopic ACTH) vs bilateral atrophy (exogenous steroids) vs contralateral atrophy (adrenal tumour).

Adrenal Insufficiency (PA31.8):
• Addison disease (primary): autoimmune > TB (in India). Hyperpigmentation (via POMC→MSH), hyponatraemia, hyperkalaemia.
• Waterhouse-Friderichsen: bilateral haemorrhagic adrenal infarction in meningococcal sepsis.
• Secondary: hypopituitarism. No hyperpigmentation; aldosterone preserved.

Neoplasms (PA31.10):
• Cortical adenoma vs carcinoma — size, weight, Weiss criteria (capsular invasion, vascular invasion, atypical mitoses, necrosis).
• Pheochromocytoma — Rule of 10s; zellballen pattern; VMA/metanephrines; MEN2; alpha-block before surgery.
• Neuroblastoma — Homer-Wright pseudorosettes; N-myc amplification = poor prognosis; HVA elevated.