+
Source: Hwang AY, Smith SM, Gums JG. Adrenal gland disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861§ionid=134128262. Accessed March 7, 2017.
+++
CONDITION/DISORDER SYNONYM
++
++
++
Pituitary adenomas (Cushing disease)
Ectopic adrenocorticotropic hormone (ACTH)-secreting tumors.
Adrenal adenomas or carcinomas.
++
Results from effects of supraphysiologic levels of glucocorticoids caused by exogenous administration or endogenous overproduction by adrenal gland (adrenocorticotropic hormone [ACTH]-dependent) or by abnormal adrenocortical tissues (ACTH-independent)
Ectopic ACTH syndrome is excessive ACTH production resulting from endocrine or nonendocrine tumor, usually of pancreas, thyroid, or lung.
ACTH-independent Cushing syndrome usually caused by adrenal adenomas and carcinomas.
++
Annual incidence of Cushing syndrome: 13 cases per million people.
Approximately 70% of cases due to Cushing disease, 15% to ectopic ACTH-secreting tumors, and 15% to adrenal tumors.
++
+++
CLINICAL PRESENTATION
++
Central obesity and facial rounding (90% of patients)
Peripheral obesity and fat accumulation (50%)—fat accumulation in dorsocervical area (buffalo hump); moon facies.
Myopathy (65%) or muscular weakness (58%)
Striae along lower abdomen that may have red to purple color.
Hypertension (75–85%)
Glucose intolerance (60%)
Psychiatric changes (55%)
Osteoporosis (50–60%)—typically presenting with back pain.
Gonadal dysfunction with amenorrhea in up to 75% of women.
Excess androgen secretion with hirsutism in 80% of women.
++
24-hour urinary free cortisol (UFC), midnight plasma cortisol, late-night (11 PM) salivary cortisol, and/or low-dose dexamethasone suppression test (DST) can identify hypercortisolism.
Plasma ACTH test; metyrapone stimulation test; corticotropin-releasing hormone (CRH) stimulation test; and inferior petrosal sinus sampling may be performed.
++
+++
DIFFERENTIAL DIAGNOSIS
++
Primary and secondary aldosteronism.
Iatrogenic Cushing due to exogenous factors.
Pseudo-Cushing due to other disease states mimicking Cushing symptoms.
++
+++
TREATMENT: GENERAL APPROACH
++
++