Cushing's syndrome

• Cushing's syndrome also called

hyperadrenocorticism is an endocrine
disorder caused by high levels of cortisol in
the blood
• Cushing syndrome is caused by prolonged
exposure to elevated levels of either
endogenous glucocorticoids or exogenous
glucocorticoids
 Causes of Cushing syndrome
Exogenous steroid administration
• Symptoms of glucocorticoid excess generally occur with the
administration of oral steroids.
• Patients with diseases that respond to steroid therapy are
especially likely to receive steroids and thus develop Cushing
syndrome. Such disorders include a wide variety of
rheumatologic, pulmonary, neurological, and nephrologic
diseases.
• Patients who have undergone organ transplants are also at
risk for developing Cushing syndrome due to exogenous
steroids required as part of graft antirejection medication
regimens.
Endogenous glucocorticoid overproduction
ACTH-producing pituitary adenoma
Primary adrenal lesions
– Overproduction of glucocorticoids may be due to an
adrenal adenoma, adrenal carcinoma, or macronodular or
micronodular adrenal hyperplasia.
 Clinical features
• Sign or Symptom % :
• Decreased libido in men and women 100
• Central Obesity or weight gain 97
• Plethora 94
• Round face (moon face)88
• Menstrual changes 84
• Hirsutism 81
• Hypertension 74
• Ecchymoses 62
• Lethargy, depression 62
• Striae 56
• Weakness 56
• Collection of fat between the shoulders(buffalo hump) 54
• Abnormal glucose tolerance 50
• Osteopenia or fracture 50
 Diagnosis
• 1-cortisol in a 24-hour collecting urin period (UFC) determination has
been widely used as an initial screening tool for Cushing syndrome
• 2-measurement of cortisol level at 8 am.
• In healthy individuals, the serum cortisol level should be less than 2-3
mcg/dL.
• 3-Dexamethasone Suppression Tests
• The 1-mg dexamethasone suppression test ,dexamethasone, 1 mg, orally
between 2300 and midnight and measurement of plasma cortisol
concentration between 0800 and 0900 the following morning. The test
has 30% false-positive rate in chronic illness, obesity, psychiatric
disorders, As a result, Cushing's syndrome cannot be diagnosed by this
test alone unless the result is extremely abnormal.
• The two-day 2-mg dexamethasone suppression test discriminates patients
with a pseudo-Cushing state. The test involves the administration of
dexamethasone, 500 μg, orally every 6 hours for eight doses and
measurement of plasma cortisol 2 or 6 hours after the last dose. The test
has excellent sensitivity (90 to 100%) and specificity (97 to 100%)
• Complications
• osteoporosis, due to the damaging effects of excess cortisol
• High blood pressure (hypertension(
• Kidney stones
• Diabetes
• Frequent or unusual infections
• Loss of muscle mass and strength
• Treatments and drugs
• Reducing corticosteroid use.
• Surgery. If the cause of Cushing's syndrome is a tumor,
recommend complete surgical removal
• Radiation therapy. If the surgeon can't totally remove the
pituitary tumor.
 Addison Disease
• Addison's disease also known as chronic
adrenal insufficiency hypocortisolism or
hypocorticismis a rare endocrine disorder in
which the adrenal gland produces insufficient
amounts of steroid hormones glucocorticoids
Etiology of Addison disease
• The most common cause of Addison disease is idiopathic autoimmune
adrenocortical insufficiency resulting from autoimmune atrophy, fibrosis,
and lymphocytic infiltration of the adrenal cortex, usually with sparing of
the adrenal medulla. This accounts for more than 80% of reported cases.
Idiopathic autoimmune adrenocortical atrophy and tuberculosis (TB)
account for nearly 90% of cases of Addison disease.
• Antibodies against the adrenal tissue are present in a significant number
of these patients, and evidence of cell-mediated immunity against the
adrenal gland also may be present.
– TB, sarcoidosis, histoplasmosis, blastomycosis, and cryptococcosis
could involve the adrenal glands.
– Malignant infiltration of the adrenal cortices, as with Hodgkin and
non-Hodgkin lymphoma and leukemia, may cause Addison disease.
 Clinical feature
• Weakness and weight loss of 1-15 kg are universal features of
Addison disease in the adults.
• Nausea, vomiting, and diffuse abdominal pain are present in
approximately 90% of patients and usually represent an
impending addisonian crisis.
• Diarrhea is less common than nausea, vomiting, and abdominal
pain and occurs in approximately 20% of patients .
Mood disturbances include depression, irritability, and decreased
concentration.
Hyperpigmentation of the skin (is considered a hallmark of
Addison disease and is present in 95% of patients with chronic
primary adrenal insufficiency.
• Hyperpigmentation is also prominent on the nipples, axillae,
perineum, and buccal mucosa (
• Women may have loss of androgen-stimulated hair, such as
pubic and axillary hair, because androgens are produced in
the adrenal cortex.

• Men do not have hair loss because androgens in males are

produced primarily in the testes
• .
• Usually, systolic and diastolic blood pressures are reduced;
the systolic blood pressure is lower than 110
 Diagnosis of Addison's disease
• Laboratory Studies
• Initially, serum electrolytes should be checked
because the results will most likely be abnormal.
– , hyponatremia and hyperkalemia are often present.
– Hyponatremia is the most common finding and occurs in
90% of patients.
– Hyperkalemia is found in 60-70% of patients.
• Hypercalcemia is uncommon and found in approximately 5-
10% of patients
• Morning cortisol levels greater than 19 mcg/dL (reference
range, 5-25 mcg/dL) are considered normal, and no further
workup is required.
• Values less than 3 mcg/dL are diagnostic of Addison disease.
• Values in the range of 3-19 mcg/dL are indeterminate, and
further workup is needed
• Cortrosyn is a synthetic corticotropin, which is intravenously
administered with a dose of 350 mg. Serum cortisol levels are
measured from blood samples drawn after 30 and 60
minutes.
• Peak serum cortisol levels greater than 18 mcg/dL exclude the
diagnosis of adrenal insufficiency because the response to
stimulation is considered adequate at this level.
• Cortisol levels of 13-17 mcg/dL are indeterminate.
• Cortisol levels of less than 13 mcg/dL are diagnostic of adrenal
insufficiency.
• Imaging Studies:
• (CT) and (MRI) demonstrate a diminished adrenal gland in
patients with autoimmune destruction and an enlarged
adrenal gland in patients with infection.
• CT adequately shows the calcification that occurs in adrenal
failure caused by tuberculosis.
• Both CT and MRI reveal adrenal hemorrhages.
• Treatment :-
• Hydrocrtison, prednisolone