Endocrinology: Cushing’s Syndrome

Endocrinology: Cushing’s Syndrome 2018-01-30T16:36:20+00:00
  • Cushing’s disease: increased secretion of adrenocorticotropic hormone (ACTH) causing Cushing’s syndrome
  • Cushing’s syndrome: collection of signs and symptoms resulting from increased cortisol

Clinical manifestations

  • Symptoms
    • Poor vision (cataracts)
    • Progressive obesity
    • Easy bruising
    • Hyperpigmentation (ACTH excess only)
    • Acne
    • Increase in bodily hair (especially females) / virilization
    • Difficulty in climbing stairs (proximal myopathy)
    • Hip pain (avascular necrosis of the femoral head)
    • Fragility fractures
    • Worsening diabetic control
    • Worsening hypertensive control
  • Signs
    • Centripetal obesity
    • Cataracts
    • Acne vulgaris
    • Hirsutism
    • Thin skin
    • Poor wound healing
    • Easy bruising
    • Acanthosis nigricans
    • Proximal myopathy
    • Violaceous striae over the abdomen
    • Prominent Interscapular fat pad

Differential diagnosis

  • Drug-induced
    • Glucocorticoids for immunosuppression
    • High-dose inhaled corticosteroids for asthma
    • Traditional Chinese medicines
  • Adrenal tumours
  • Cushing’s disease
    • ACTH-secreting pituitary adenoma
  • Ectopic ACTH secretion
    • Small cell lung cancer
    • Carcinoid tumour
    • Carcinoma of the pancreas

Investigations

  • Confirm diagnosis
    • Midnight serum cortisol for screening (cortisol nadir occurs at midnight)
    • 24-hour urinary free cortisol (high, usually 3x upper limit of normal)
    • Overnight dexamethasone suppression test (failure to suppress)
  • Inferior petrosal sinus sampling to determine if there is a pituitary source
  • Magnetic resonance imaging of the brain to look for pituitary adenoma
  • Computed tomography scan of the abdomen with adrenal cuts to look for adrenal adenoma
  • DEXA scan to look for osteoporosis

Management

  • Multidisciplinary team approach
  • Patient education
  • Withdrawal of offending drug – stop TCM slowly
  • Surgery (definitive)
    • Trans-sphenoidal hypophysectomy for pituitary adenoma
    • Adrenalectomy for adrenal adenoma
  • Medical
    • Ketoconazole if surgery unsuccessful or while awaiting surgery
    • Metyrapone (second-line)

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