Cushings Syndrome

Question 1

What is Cushing’s syndrome?

Answer 1

An excess in glucocorticoids (cortisol)

Question 2

What are ACTH dependent causes of Cushing syndrome?

Answer 2

Pituitary adenoma: higher in women
Ectopic tumor: higher in men

Question 3

What are ACTH independent causes of Cushing’s?

Answer 3

Adrenal cancers

Question 4

What are iatrogenic causes of Cushing’s syndrome?

Answer 4

Excess exogenous glucocorticoid

Question 5

What happens pathophysiologically in the body with excess glucocorticoids

Answer 5

Increased gluconeogensis
Increased lipolysis
Increased protein catabolism
Suppression of gonads

Question 6

S/s of Cushing’s syndrome

Answer 6

Obesity, diabetes, diastolic hypertension, hirsutism & depression
• Rounded face and buffalo hump
• Fragility skin
• Osteopenia
• Osteoporosis
• Muscle weakness & proximal myopathy

Question 7

What are complications of Cushing’s syndrome

Answer 7

• Associated prothrombotic state
• Psychiatric symptoms
• Impaired health related quality of life
• Increased risk of CV disease
• Fractures

Question 8

What is the Dexamethasone suppression test?

Answer 8

Dexamethasone is a glucocorticoid that decreases CRH thus blocking ACTH receptors
1mg po is given at bedtime
Serum cortisol is checked in the AM if <1.8 Cushing’s is ruled out
ACTH independent causes will not be sensitive to this

Question 9

What is the salivary cortisol test?

Answer 9

Late night (10-11pm) salivary cortisol is drawn >250 is considered abnormal

Question 10

What is the 24 hr urine cortisol test?

Answer 10

Free cortisol >50 or Free cortisol to creat ratio >95 are indicative of high cortisol

Question 11

When is imaging recommended to r/o Cushing’s and what type of imaging

Answer 11

When it’s ACTH independent you can get an unenhanced CT

Question 12

When is medical therapy indicated for Cushing’s syndrome?

Answer 12

When the individual denied surgery or it was unsuccessful

Question 13

What are the medications for hypercortisolism

Answer 13

Ketoconazole 200 mg PO q6h
Metyrapone 1250-1500 mg/day in divided doses
Mitotane 3-5 g/24h

Question 14

What is the medication for hypergonadism

Answer 14

FLutamide

Question 15

What medications can be administered for hypermineralcorticoid hypertension

Answer 15

Aldactone or norvasc

Question 16

ACTH independent surgical options

Answer 16

Adrenal tumor resection

Question 17

ACTH dependent surgical options

Answer 17

Tumor resection or removal

Question 18

If bilateral adrenal carcinomas are present what disorder should be checked for?

Answer 18

Carny’s complex a rare genetic disorder that causes multiple tumors

Question 19

Medical treatment for metastatic ACTH producing tumors

Answer 19

Somatostatin impairs the hormonal release and decreases rapid cell growth
Most of these tumors have Octreotide receptors

Question 20

What is a good post operative sign of a resection of an adrenal carcinoma

Answer 20

Secondary adrenal insufficiency

Question 21

Medication post operative managment for adrenal carcinoma resections

Answer 21

Mitotane for 2-5years post op
Screen for secondary hypothyroidism
For primary adrenal insufficiency give hydrocortisone 15mg in am and 10 pm

Question 22

What are post op complications and management of Cushing’s syndrome

Answer 22

Hyponatremia: first 2 week post op
Hypothyroidsim
Cortisol w/d syndrome: fatigue, increase hydrocortisone
MRI in 3 months of pituitary