Hypercortisolism Flashcards
What is the difference between cushing syndrome and disease?
Syndrome is Hypercortislism
Disease is an adrenal tumor
What is seen clinically in Cushing Synd?
Purple Striae
Central obesity
Buffalo Hump
What is Exogenous vs Endogenous Cushings?
Ex: Oral Prednisone for non endocrine diseases (ACTH independant)
Increased secretion
What are the categories of Endogenous Cushings?
Pituitary/Hypothalamus/Ectopic Tumor
- Inc Cortisol
- Inc ACTH
- ACTH DEPENDANT
Adrenal Glands
- inc Cortisol
- inc ACTH
- ACTH INDEPENDANT
What is the Cause of ACTH DEPENDANT Cushings?
Pituitary (CUSHING’S DIS) 90%
Ectopic ACTH 5-10%
Ectopic CRH rare
What are the findings in Cushings due to Ectopic ACTH?
ELEVATED ACTH (5-10x > Cushings Disease)
Hirsuitism
Hyperpigmentation
What are the types of endogenous ACTH-INDEPENDANT Cushings?
Unilateral Adrenal Disease: -Adenoma -Carcinoma Bilateral Adrenal Disease -Micronoduar hyperplasia -Macronodular hyperplasia
What is the Difference between Adrenal Adenoma and Adrenal CA?
AD: Unilateral, Well circumscribed, normal adrenal cortex histology
CA: Large, irreguar shaped nodules, 5-20cm, areas of hemorrhage/necrosis, nuclear pleomorphism/mititic figures, capsular and vascular invasion
What is the Process for diagnosis of Cushing’s Syndrome?
- Confirm Hypercortisol
- Determine Subtype
- Localize source of overprod
What tests are done to confirm Hypercortisolemia?
24 hour Urinary Free Cortisol Excretion
11pm salivary or serum cortisol
Low dose dexamethasone supression test
What are the Urinary Cortisol levels indicative of Cushings?
150 likely Hypercortisol
What is Pseudo-Cushings Syndrome?
High Cortisol from another disease process that stimulates CRH or ACTH Production
What are causes of Pseudo-Cushings SYndrome?
Major Depressive Disorder Chronic Alcoholism Severe Stress Major Surgery Severe infection Severe Obesity/Polycystic Ovary Rapid Wt loss/Anorexia Nervosa Meds: Carbemazapine (dec cort clearance) DO DEXA Supression test NOT 24hr Urinary Collection
What is Midnight Salivary Testing?
Chew on cotton swab for 2 min
put in container
7.5 likely cush
What is the low dose DEXA supression test?
1mg Dexa at 11pm
next day measure morning serum cortisol
10 likely Cushings
WHat is considered a confirmatory test for Hypercortisolism?
24 hour urine PLUS another test
What imaging studies are done for Pit, Adrenal, or ectopic?
Pit: MRI
Adrenal: CT
Ectopic: Chest CT (50% of tumors)
What is the Tx of Cushings?
Remove Adrenocortical Adenoma or adrenalectomy
-Other Adrenal Gland may atrophy
Adrenal CA
-Debulking or mitocaine to reduce Cort for QoL improvement
What is done to differentiate Pit vs Ectopic Cortisolism?
High Dose DST
if Pit you WILL have ACTH supression
Ectopic Cannot be supressed
Inf Petrosal sinus Sampling
compare drainage of each side of pituitary after giving CRH
What is the Tx of Cushing’s Disease?
Pit Surgery
Pit Irradiation
Adrenal Surg
Drug Tharapy
What is the cause of death from Cushing’s Syndrome?
Immune Supression
Sepsis
WHat are the Drugs that are used for Cushing’s?
Aminoglutethimide: dec all 3 -Blocks chol => Pregnenalone Ketoconazole: dec cort, ald, DHEA -Blocks 11 beta hydroxylase Mitotane: Dec cort, Ald , DHEA -Blocks 11 beta hydroxylase (same as ketoconazole)
What is the Tx of Ectopic ACTH Syndrome?
Resection of 1^ tumor
Radiation/chemo
Bilat. Adrenalectomy
Medical Adrenal inhib
