Station 5

Question 1

What is cushings syndrome?
History

Answer 1

Hypercorticol

Head
-Rounded face
- Cataracts (steroids)
- Acne
- Visual field defects / headaches (pituitary)
- Oral thrush

Neck
-Buffallo hump
- Acanthosis nigrans

Body
- Central obesity
- Worse diabetic controll - polydipsia …
- Hypertension - headaches
- Increase bodily hair

Limbs
- Proximal myopathy - unable to stand from sitting
- Fragility fractures
- Avascular necrosis of femoral head
- Easy brusing

PMH
COPD / Asthma / bronchiectasis
Malignancy
inflammatory conditions - eg Rhem etc

FH
MEN

Social
Smoking
Diabetes
Function

DH
Steroid use

What is thier CONCERN

Question 2

Differnet types of cushings and how to differentiate

Answer 2

Exogenous
- Secondary to steroid meds

Endogenous
- ACTH dependent -> Pituitary or ectopic neuroendocrine (most commonly small cell Ca / carcinoid)
- ACTH independed -> Adrenal carcinoma

Confirm diagnosis
Screen with

Question 3

Cushings exam

Answer 3

End of bed
- Wheezing
- Central obesity
- Hairloss

Hands
- FIngerprick

Arms
- Bruises
- BP raised

Head
- Visual field defects
- Oral thrush

Neck
- Acanthosis nigrans

Abdo
- Striae
- Scars from adrenal surgery

Legs
- Ask to stand from chair without arms to assess proximal myopathy

Question 4

Cushings ix

Answer 4

Observation chart
- Especially HTN and Tachy (episodic may be concominant phaeo in MEN)
- Finger prick glucose

Urine dip - glucose and protein

Bloods
Confirm diagnosis - overnight dexamethasone test.
ACTH levels
- High Pit / ectopic tumour
- Low Adrenal

Imaging
- CXR for lung Ca
- MRI pituitary
- CT adrenals / chest dependent on likelyhood

ECG - for LVH

Question 5

What do you have to stop before doing overnight dex supression test? How does it work?

Answer 5

HRT
COCP
pred / dex etc

1mg dex at 11pm
Measure cortisol at 9am (should be supressed)

Question 6

Slightly unclear if cushings from pituitary or not after MRI what test can you do?

Answer 6

Inferior petrosal sinus sampling

[Measure ACTH levels in vein draining from pituitary]

Question 7

How do Ketoconazole / Metyrapone work for cushings

Answer 7

reduce baseline cortisol by inhibiting 11b hydroxylase

Question 7

Management of cushings

Answer 7

Conservative
- Patient education
- PT / OT if required
- Slow withdrawal of causative agent

Medical
- Management of HTN / diabetes / bone protection
- Steroid sparing agent eg Azathioprine in crohns
- Ketoconazole / Metyrapone while awaiting definitive surgery ->

Surgery
- Trans-sphenoidal hypophysectomy for pituitary adenoma
Adrenalectomy for adrenal adenoma