•  A 42-year-old obese male who does not smoke, presents with diastolic hypertension. Physical exam shows a full, plethoric appearing face, increased facial hair, truncal obesity, and purple stria around the abdomen with scattered echymosis over the entire body. Labs show an HgB of 18 (12-16), a WBC of 18,000 (4,500-11,000) . The leukocyte differential shows and absolute neutrophillic leukocytosis and absolute lymphopenia and eosinopenia. CXR is normal.
  • A condition that refers to the manifestations of hypercortisolism
  • Iatragenic and pituitary adenoma are most common causes

    Cushings Syndrome
    Iatrogenic Cushings

    patients taking steroids is the most common cause of Cushings Syndrome.

    low ACTH  
    Pituitary Cushings
    Pituitary Adenoma

    most common pathogenic cause (70%), the majority of adenomas are benign.

    high ACTH
    Cortisol responds to dexamethasone supression test 
    Ectopic Cushings
    Small cell carcinoma of the lung.

    ectopic ACTH secretion

    extremely high ACTH
    Cortisol does not respond to dexamethasone supression test
    Adrenal Cushings
    Adrenal adenoma   low ACTH  
    Bilateral hyperplasia   low ACTH  
    Adrenal Carcinoma   low ACTH  
  • Symptoms
    • depression and psychological changes
    • oligomenorrhea
    • growth retardation
    • weakness
    • acne
    • excessive hair growth
    • symptoms of diabetes (polydipsia, polyuria, dysuria)
  • Physical exam
    • hypertension 
    • central obesity
    • muscle wasting
    • thin skin that easily bruises
    • purple striae
    • hirsutism
    • moon facies
    • buffalo hump
  • Labs
    • screen for 24 hour free urinary cortisol as well as a serum cortisol level
    • ACTH to localize lesion
    • high dose dexamethasone supression test (localize ACTH high disease to pituitary)
    • hyperglycemia
    • hypokalemia and hypernatremia
  • CT and MRI to localize lesions
  • Inferior petrosal sinus sampling
  • Chronic alcoholism, depression, diabetes mellitus, adrenogenital syndrome
  • Resection of source
  • For non resectable tumors:
    • ketoconazole (inhibits P450)
    • aminoglutethimide (inhibits P450)
    • metyrapone (blocks adrenal enzyme synthesis)
    • mitotane (adenolytic)

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