0usesS

.cIP Jof cushing

Adrenal qland 0
*Adenal qland compoied of Adenal coitex 3 Adienad medulia
*AArnal Cotex composed af3 2ones a GER Eram .outside to inside)
1.tona GTiomeHidoso
2.2ona fosiuata Ohomane @contrel @achon 011
3. tona ichculais
ona Glomeulaa
1. Hoicne Aldosicrole
hos otlg PpedtSie
2- ontrol: iainly Controiled
hy Na,k, RAAS 3 minumal uidol y ACTH Na w
VNa tkstmula Aldotteone secnton
3.Action: TNa eabiorphon frotn hidne tubuler 2k excrelion Kidneg
4.11: Cona'S Syndeme lhsperaldaskeronism)
5.W: hypoaláostciotim (Aist.ocorhial failue) (Aádiwens
ona koasiculata
1.Horfhone: Coñisol
2. Control: Pituitary AcTH
3. A chion: 3 4 3
.1CushingSyndrme
5.: Adrtlocortcol foiure (Addislon's disease)
-ZonaRefiudoni:
1. Hormone: 0dena androgens
2. Cont-ol ACTH
3. Achion Anabobe on nwsle, pubit Jauillary hair, minor on rtiainity 223 Senual chakat+s

. Gunjehtal odrenal igferplasia

5.v hdretoorh ad faiure
xAdrenal medulla
Secek Cattcholamines (cpinephrine. & no-ep inephine) which are cataboke
homones Setrttd in jsponse to Sympathehe achivation trees 3 emeyences)
whan M:pheochiomoyfoma

Achons of cohisolneabelicant te Lihe

Hetabolic
1 CHOvglusose uhli2ation by isues (= insulinesistance =diabetogenid, So
-Diabetes its physiolo;ial alian is to maintain blood lucase luel spieutnt yfyn
lik
2- P-Okin Cotabouc effectan prolcins (musde weaknes,osteopobosii)exte
-Patholagicaly: 1. mustle weakness 3 was ing 3.delayed wound hea liny ( collagen)
2. osttop0rasis 4. Vascular phepa (atv collagen
kuptue of vered) 5. Striae: wide >1 cm,depprered,rdth
3.fat mobüa.hon of fat fr»m extremihes to cenker dt 4 colla,gen.depessed
Pothologicaly: 1.moon face Poyythemiareddih
2. Truncal oleritylemon on motthshick
3. Ssupraclauitular fat aCumnulafionbusalo hump
anti
1. Antiinfiommotoijinhbits phayoyfasiu
2- Anh FibkotL u flooblast
3 Aniallagic i cosonipholk
4.Anh vit D vca 3 cause bone RSophion
O3
Like
.aldosteone Like: HT 3hypholemia
2. andragen lie: OHisuhisn in Females Oacne Eay clolurt of ePipkhgiu (shovt stadu
3. jthiopoiehin like :Poly ythemia :@ Redish shiat in childen)
facial ple hota
EFfect on Bane nQHo)
-TReC pYrodiston Polyauthemio
neuhophir mildl infotad lukatyhic caunt
basophls,eainophid, monocytesvmyhogyir
L aphialleantieEla. infechons
Shot Stoture dt
ealy closueof epiphgis divecfly GH Secrehion
osfcoporosis (cotabotc ellet on bont mahix)
inhibit insuln ldre ghowth facta-1 &Somatomédin)
Thstapenhi uses
anninklo mnatory ai: ucCD LoHtiol has antiVitD
anheaboficas: Ssc
anh aliergic as:6A
1mnosuppresrive
Shock to T SP
BM Failse Captashic anemia)
ALLScLL ( yphoytu)

Cushing syodrome

Causes o Cushing Syndiome

ExochouL
mic cauSe of Cushin

Iathogenic hom midilaly piesibed CST

Kctal ,Topical
any rou: onB inhaled,parenksod,
its T
Dase houteof admnuhain, duwafon, cononitantduyi prolonginy
fators: Potencj , ,

Conhnuostintake ofSieoids fov z7 weeks

Jong teHm Stetoids:
Eldogenous:
ACTH dependent: ACTH, LOHÍol2cushing
1. fitluta adenonamjc cauise of ACTH dafend.nt cushing
xmlc of hgpesuioitm Suall miuo adenoma (no piesi ue manifestalions
in Gdat Called 28 cushing CUshing disease
2- Ectopic ATH SCehon: as a pauit of paantophske Syndiome
TM COuses:1.Bronchegenic carnoma 2. Coinoid tumors 3. Poncreae tulMor
36 4 Pheochramo tytoma 5. medulla Carcinoma of thaid6-HCC
3.EctoPic RHSeuehon

ACTH independant: JACTH 1 Cushing

1.Adrenal tumor: 1. unlattal adrenad odenoma (mlc cause ofadenad cuchng)
1 cushin COFCnoma

mlc, Coue pf hygzrcor. 3. Bilateol n Odcnoma tasis

ticoism, in(cuiarenn
1-Hdrex Tgpeploiia MaCofnodular g Piqnented adrenal nodular

P of cushing
1 fathognomoni Sizns Samgtons:
1. Stiae: widey1 um , depressed, iedáish puple in clor
2. Easy busing mulhple echymoic paBches 3 skin
3.facial plethora
-Procmo mppathy
5. unexploined osteop1osis 2 musosllaa
b. obesity- Short Statwt in childrcen
2Suggeshve features:
12 diakekes
2. Fat: -moon face
- cen al obesity (lennon matth Sthik aprearaKe)
SLpaciaidarfat occummulahion.>Biffl uump
3- Prokins. dlayed wound healing
4.0JdaskoneLiki achions: HTAhpokalemia
acne hirsuhism, ealy closue ofepiphyiis Shot Statue)
5androgen uke
Polay theno
7. infe hons
EmiiDUl icgulakfs
3 Piy chologiod distuwbancs euphora daprtuion
or

miuradknoma)
) No pieJiure manifstations (Sually pituton g
ACTH instead af 4
in 5 [AcTH dependent) cushing dt
tol hypupimentañion J anti
Shmwale MSH

of Sc coliagen
(ushinoid Striae: 1. wide Sdepreced destihon
dt
y
2.Reodsh ppledt thin shin 8 poytYthemia
3. oon Fale
pt: ifacial piefhora
x face of Cuhing
2. Acneshisuksm 4- pupura

Cushio
obesit
cenbal
G1enealikd
dkish Shioe
whitt JDiae
Bone mineraldenuity Bone mintal densily
3 +t
featuses
No other Cushing
xwtlosr in cushing: Ecfop CShing
cAuses of ShotStature
1.oskporosi
cloiut of epiphys
2. cany 1
Cortiol ihibits insulin.ike groih Factor
2
 Diagnoshic worhup of Cushiny syldivonle

Hx phusiol examinadoncP ho.should be teStd:

PS witk hiyhy pathognomnic signs 3 synptams of Cushiay
2.Pts with Suggestie featucs unusal for age.au HTN
3. Shot s obese children
4-PLs wth adrenal incidentaloma :Acidertal dutariy of adienod ma
by imoginfudkes peuforned tor aCaJe yhelatd to ad-enal dwae

Excude eXojenou CS by
1. Thorough drag Hx
2. Basal ONDI leVel af L.0o Am: vess low Basal conisol. exqgenous CS
High 6asal tartiol (00considered to dxor scree far Cuthing but anyued
fo exclude eXogenous Cushing

32 Stp apponck for dx of Cushing:

Step1: Is it cuwhing ?7,b serneningtests dependinyon patholoy ol Cuuhing
1my oveHiht Dekamethasone Suppretantet
iden: failule to Stop cortiol produton despite Sppielion of AcTH by dexamethaun
Skeps: AdmnGier 1mg desomethayone at ll pm A neouAe cohíol iekel behm 8-84anm
next moMiDg
Results ugldL (Emol/),unSuppiesibke -Ne for Cushiny
(Level o 2
Cokhsol Suppss ible ve tor
O -Do Ou dose 0ST:
1dea the Same a5 above

. Steps: Adminise o5 mg Desamcthasone etay 6 hus kav 2dags ( tamy 3Pn,4 Am,a
meas we Cotisol fevel hs after the last dose
Resuts: the Same as obovre (mok spufi thon.ovenight DsT)

ophma test for Pseudocuuhing

u h in0 r e to hol (uf)
2
Sheps: at least 2 measunents, uwe volame <3L,
idea: eXusive corhisol phodulion ine Cieaoine clearane > boml|min
eslts: elevohions moke tham3 fimes the ULN is daynoshic
Lotenight salivarjcoiol: ot in Et"
idea: loss ol no-inal duunoal coriol prodchon with abnomaly high late niyht
CoIol suehon
- tps: Somple.coliectcd by passive drookny ovchewing cotton piedaet "Salvete"
1.1mins
- not Suitabfe fak depresSivcpts.night shsEtworl@s dt altted Civcadian ththm

LResulHsO2weJoeeniag keytsareneded tojotostepz. (we usally staus

with ove-night DST2uh- uEC then confum uithtáe mort Jpecihie,
-12,3 Sceaniny tst: LDDST) to exclude Pendocushidg:1.Prrgnang
2. cko 3. chroi liver 4.Morlid obesity 5. depresian 6.anhelychotiusA0A
7. Altohol dependence 8.G-lucocortatoid rtsictana 9.poordy calliroled DM

1 e,1-ve»cinical supitjofn
highly clinial sspitionsrpat xveening test
-Ve Stop the woup
32-ve Sceelingtesti Stop the wovtrp

Step 2: loah u. Canse of cushin1 by biochemial evaluaha It then kodioogicol:

Bipchemil evaluatuon
Oighdlase D3T
idea: High dose dexomcthasone (Ib my|2 days) Can Suppheis cOHisol if mildy elewakkd
ad renad Ectopic
in case of pituitary but tan'tSPps modevotely to highy èleuahed corhisol in
Odrenad Ectopic eushing Kspeutivel
Steps: . ma eveH 6 his fo 2 days measue preest-basal couisol leve
0t9 amS posttest corisol level 48 hus later
-liesuts:Suppicsion5o7CD
Suppession5o ol pretcst basal couniiolAdrenal or ectopa

Honiba ACTHLow ACTHDdrnal

High ectopic

2Radiologiul evaluahion
Adre nolTfor adicnad lesions
EctopiL Cuhing:
CTMRT H3N, chet abdomenPelvis
OctROSan

- MKL en sllo fwiua tor pituitarj aden oma: L.ovMal in abot so7 of pts

wth CD
-BilateaTnfeior petrosol SinurSampligy(BTA
g0ld Handard todilfereniate ben pihutary ctopic cuhin

Basal LorhJol jevel : only wed to exclude exojenos Cuskiy

Honing Corfiol leel: -Not used for DX

5 ugldl jeneally excludes CS y5o Suygeshive

- Joss ol oHmal cinadian yhm alio in:
Dight Shft wovkas
drreaie plu
ttiialy ill pts
other lab findiqgs:poy ythemia &milut wBc hpokalemia hypocalcemia
ypyyutia jycoluria hperin sulktenia (t insuljn resistan
Treatmant ofCushing
Surgery
The 1 only dehnitiv teotmant
Ophions: .Tvanssphênoidal | Tlansnaiol selechie pituitay njuadn etony
unilattrol [bilattod adrenalectom ansuanial approach i

2 Rodiotion theepy: al fr Sugery macho odnoma

3 Medical treatment
indication s bekon Suiguy far preparakionof pt
1 thevapy in caei of ver bad prog nasi
- Adenocorhiual Cainoma

ectopic uuhing
failue of Swjical t
) Acutc emejent Complia fony of hype-CoHiLolism
Inopuosle higk opu-akive nik pt

ophions hepatotoxk t
adrena OKetoconatole 4. aminolate thinide
-DHug inhibiting_Steoid Synthesis:
Mitatane
metiaponepensive

OupACTH relea.se:
1. Bromo Cipine Cdopamnt agonit
2.octheohde (Somatostotine ognist
3. VolproiLaid (GABA M)
upoheptodine (.Serotanin anfagoniit)
-Corhsol receptor antojonilt: {ifephstone