Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
28 March 2007

WHAT IS THE ADRENAL GLAND?

            The column this week is devoted to two different patients.  One was a lady whose adrenal gland ceased to function normally and the other was a gentleman whose adrenal gland developed a tumor and became too active.  When they developed the symptoms that brought them to medical attention, they hadn’t a clue what the adrenal gland was or what it did.  Their questions are answered below.

            The lady was 36 years old.  Over about 6 months-time, she had lost twelve pounds that she wasn’t trying to lose.  Her appetite had just waned and she just wasn’t hungry.  She indicated that she had become weak.  Previously, she had been a jogger running several miles three times a week.  She indicated that she simply could not do that any more because she felt weak, not because she was short of breath, but because she was weak.  She was an executive at a local business and indicated that when she got home at night, she would fall asleep before fixing supper.  She said she didn’t think she was depressed but she said that she was getting that way because of her symptoms. 

            So many things might cause the above complex of symptoms and multiple laboratory tests were done.  When the blood sodium concentration was checked, it was found to be substantially low, and the blood potassium concentration was substantially high, and she was on no medications of any sort.  This was a flag that she had a condition called “Addison’s disease” in which the middle part of the adrenal gland simply stops working.  The area is called the cortex of the adrenal gland and its hormones that it makes are called adrenal cortical hormones.  They are of three types.  One is called cortisone, another is called aldosterone, and the third is a sexual hormone estrogen.  In men, the sexual hormone made by the adrenal gland is testosterone.  Subsequent history from this lady indicated that her periods had stopped so she was deficient in all of the adrenal cortical hormones.  She wanted to know why and what had gone wrong to cause this, unfortunately, we don’t know.  The text books elude to so called “autoimmune” problems where the person becomes allergic to their own adrenal gland and try to reject it.

            Fortunately, treating this lady was relatively easy.   All that is needed is simply to replace the hormones that she was not getting before from her own adrenal gland.  They are all available from a medication that is quite remarkably cheap.  She gets Cortisol 15 mg in the morning and 10 mg at night, and gets a replacement hormone for Aldosterone, and a replacement dose for her estrogen.  She has regained her weight.  At 36-years-of age, she is not at all happy about taking three pills a day but it seems to be a better choice than feeling like she did before.  Unfortunately, there is no predictable reversal for this problem and she will be on medications lifetime. 

            The second case is that of a gentleman who came to the emergency room with what was initially thought to be a “panic attack”.  His heart beat was 170 beats per minute, his face was bright red, his blood pressure was 200/110 (normal 120/80) and he said that he just felt frantic.  Talking to this gentleman was difficult because of his anxiety and sensations that the whole world was wrong.  He was given a sedative and over about 15 minutes to half an hour, his symptoms got much, much better.  It was then that a coherent history was obtainable.  He said that he was at home working at his desk in the early evening and these symptoms just came on all of a sudden.  He said that there wasn’t any unusual problem.  He said there were no unexpected or gargantuan bills that he wasn’t able to pay.  He says that he just didn’t know why he got these feelings.  He said he had little spells like this two or three times in the past again without provocation.  About an hour after he came to the emergency room, everything seemed to be normal.  His pulse was back to normal, his blood pressure was back to normal, and he was no longer feeling the anxiousness that he had.  It was felt that he had a panic attack and medications to prevent this in the future were discussed.  He declined them saying that he didn’t think that he needed the medication to treat something that had happened just one time. 

            Two months later, he came back to the emergency room with the same situation.  Again, a medication sedative was provided and he got better in the course of an hour, as before.  Now he was interested in having something to prevent these from coming and a medication was provided.  Unfortunately, that medication didn’t work and he had the third event.  That is when I first encountered this gentleman and his history.

            He did seem to be a very anxious individual and I could see why the diagnosis of  panic attacks were made in the emergency room.  But there is a tumor that occurs in the adrenal medulla in some individuals.  It is very rare, being only one in every 40,000 people, but it does occur and that one person is very hard to pick up.

            Be that as it may, the tests were done and did confirm that he had an adrenal medullary tumor called a pheochromocytoma.  This is a very difficult tumor to deal with and he was eventually surgically treated at Mayo Clinic where the tumor was found to be benign and completely removed.  It is now three years later and he has had no recurrence of the symptoms that he originally had.  So what is the adrenal gland?  It is a gland about a big as a walnut that sits on the top side of the kidneys on both sides.  It makes hormones designed to protect the body against stress.  The adrenal cortical hormones protect against long-term stress day to day.  The adrenal medullary hormones that come from the center of the adrenal gland, protect immediate terrible crises such as moving vehicle accidents or lions or tigers or bears.  But an inordinate amount of either one of these hormones or deficiency of them can cause major problems.  They are very hard to diagnosis and the healthcare professionals at your local clinics are aware of this type of problem.  They may not get picked up on the first or second visit for the problem, but when things continue not to work, diagnoses are eventually made.  Unfortunately, these types of problems are relatively easily dealt with and symptoms can be stopped on a long-term basis.