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Cushings Syndrome

Stephen Ou R2
May 17, 2013

Learning Objectives

Discuss the different etiologies of hypercortisolism.

Recognize the clinical manifestations of Cushings syndrome

Understand the screening tests for Cushing's syndrome

Establishing the cause of Cushings Syndrome.

Definitions
Cushings syndrome: constellation of
symptoms associated with cortisol excess.
Cushings disease: Cushings Syndrome due to
pituitary ACTH hypersecretion.

Clinical Manifestations
Most Specific
- Spontaneous
Bruising
- Proximal
Myopathy

Nonspecific
- Central obesity w/
extremity wasting
- Dorsocervical fat
pads (Buffalo
Hump

- Abdominal striae
- Round facies
(Moon Facies)

- DM

- Depression

- HTN

- Insomnia

- Obesity

- Psychosis

- Oligomenorrhea

- Impaired Cognition

- Osteoporosis

- Hirsutism
- Fungal Skin
Infections
- Nephrolithiasis
- Polyuria

Clinical Manifestations
of Cushings Syndrome
Facial Plethora i.e. Moon Facies

Dorsocervical fat pad i.e. buffalo hump

Its not always Cushings


Other common conditions associated with high cortisol
levels

Pregnancy
Etoh dependence
Morbid Obesity
Depression
Poorly controlled Diabetes
Physical stress/Malnutrition/Chronic Exercise

Bottom line: There are many other causes of


hypercortisolism (Best to test in the outpatient setting)

Diagnosis of Cushings Syndrome


Obtain a careful history to exclude exogenous
glucocorticoid use.
Perform at least two first-line biochemical tests
to obtain the diagnosis:
Urine free cortisol (UFC) (at least two measurements)
Late-night salivary cortisol (two measurements)
1-mg overnight Dexamethasone Suppression Test
(DST)
Longer low-dose Dexamethasone Suppression Test
(LDDST) (2 mg/d for 48 h)

Algorithm for testing

Case Vignette
A 67 year old woman is evaluated weight gain, hypertension and T2DM
over the last 2 years. She has also developed muscle weakness of the
lower extremities over the last 6 months. Physical exam is notable for a
BP of 154/92, facial hirsutism, obesity, abdominal striae, proximal
weakness and peripheral edema. Laboratory studies notable for
potassium of 2.9 meq/L. Which of the following diagnostic tests should
be performed next?
A.
B.
C.
D.
E.

Adrenal CT
C- peptide measurement
Glutamic acid decarboxylase antibody titer
Pancreatic MRI
24-hour urine free cortisol excretion.

Case Vignette
A 67 year old woman is evaluated for a 2-day history of severe muscle
weakness of the bilateral upper extremities. She has also experienced
significant weight gain, developed hypertension and T2DM over the last 2
years. She also developed muscle weakness of the lower extremities 6
months ago. Physical exam is notable for a BP of 154/92, facial hirsutism,
central obesity, abdominal striae, proximal weakness and peripheral
edema. Laboratory studies notable for potassium of 2.9 meq/L. Which of
the following diagnostic tests should be performed next?
A.
B.
C.
D.
E.

Adrenal CT
Hemoglobin A1c
Glutamic acid decarboxylase antibody titer
Pancreatic MRI
24-hour urine free cortisol excretion.

Take Home Points

There are a number of different causes of hypercortisolism including


Cushings Syndrome

The clinical manifestations of cushings syndrome vary in specificity

Diagnosing Cushings syndrome includes the use of at least two first


line biochemical tests.

References
UpToDate: sections on cushings syndrome
Epidemiology and clinical manifestations of Cushings syndrome
Establishing the diagnosis of Cushings syndrome
Establishing the cause of Cushings Syndrome

The Diagnosis of Cushings Syndrome: An Endocrine Society


Practice Guideline. JCEM 2008 May; 93(5): 1526-1540.
Pocket Medicine: Cushings Syndrome