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Cushing’s Syndrom e

Cushing’s Syndrom e. Stephen Ou R2 May 17, 2013. Learning Objectives. Discuss the different etiologies of hypercortisolism . Recognize the clinical manifestations of Cushing’s syndrome Understand the screening tests for Cushing's syndrome Establishing the cause of Cushing’s Syndrome.

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Cushing’s Syndrom e

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  1. Cushing’s Syndrome Stephen Ou R2 May 17, 2013

  2. Learning Objectives • Discuss the different etiologies of hypercortisolism. • Recognize the clinical manifestations of Cushing’s syndrome • Understand the screening tests for Cushing's syndrome • Establishing the cause of Cushing’s Syndrome.

  3. Definitions • Cushing’s syndrome: constellation of symptoms associated with cortisol excess. • Cushing’s disease: Cushing’s Syndrome due to pituitary ACTH hypersecretion.

  4. Clinical Manifestations

  5. Clinical Manifestations of Cushing’s Syndrome Facial Plethora i.e. “Moon Facies” Dorsocervical fat pad i.e. “buffalo hump”

  6. It’s not always Cushing’s • 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)

  7. Diagnosis of Cushing’s 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)

  8. Algorithm for testing

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

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

  11. Take Home Points • There are a number of different causes of hypercortisolism including Cushing’s Syndrome • The clinical manifestations of cushing’s syndrome vary in specificity • Diagnosing Cushing’s syndrome includes the use of at least two first line biochemical tests.

  12. References • UpToDate: sections on cushing’s syndrome • Epidemiology and clinical manifestations of Cushing’s syndrome • Establishing the diagnosis of Cushing’s syndrome • Establishing the cause of Cushing’s Syndrome • The Diagnosis of Cushing’s Syndrome: An Endocrine Society Practice Guideline. JCEM 2008 May; 93(5): 1526-1540. • Pocket Medicine: Cushing’s Syndrome

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