Cushings syndrome - endocrinology ppt...

A ppt on Cushings syndrome

1. CUSHING SYNDROME

2. CUSHING SYNDROME It is characterized by excess cortisol secretion. More in women of 20- 40 yrs Acquired deficiency of 11-beta HSD Licorice consumption in excess Characterized by – Hypertension Hypokalemia Alkalosis

3. EFFECTS OF CORTISOL PROTEINS- Proteolysis - Increased AA uptake by the liver - Alanine- gluconeogenesis FAT- Lipolysis- FFA & increased TGs . - Redistribution of body fat CARBOHYDRATES – Glycogenolysis - Increased FFA & Insulin resistance

4. Mineralocorticoid like action – Hypertension, hypokalemic & alkalosis Steroid induced psychosis Sex steroid like action – acne & hirsutism Circadian rhythm – 8-8.30 . -Peaks at 1.30-2 - Baseline@5 pm f/b a flatcourse Eosinopenia

5. EFFECTS ON OTHER SYSTEM EYES- Glaucoma, cataract GIT – Ulcers CVS- HTN , LVH Decreased linear growth Bone- Decreased bone formation & osteoporosis

6. Skin, muscle & connective tissue :- - Collagen breakdown, skin thinning Muscle atrophy Reproduction – Amenorrhea & decreased libido Hypercoagulable states Anti- inflammatory Immunosuppression

7. Causes EXOGENOUS – Steroid intake E NDOGENOUS CUSHINGS –ACTH DEPENDANT . - PITUITARY (M/C) - ECTOPIC – Small cell lung CA(M/C), carcinoid, medullary thyroid CA, phaeochromocytoma (rare) ACTH INDEPENDENT – Adrenal adenoma>adrenal CA PSEUDOCUSHINGS- Chronic stress response – alcohol, obesity , depression , PCOD & metabolic syndrome.

8. DIAGNOSIS Midnight serum cortisol - <1.8mcg/dl or 50nmol/l Midnight salivary cortisol - <5.5nmol/l 24 hrs urine free cortisone test – impractical Overnight Dexamethasone suppression test:- Dexamethasone (1 mg) given @1 1 pm – Plasma cortisol at 8 AM Suppression of cortisol to <1.8mcg /dL – normal HPA axis Low dose dexamethazone suppression test Plasma ACTH - > 10-20mg/dl (>20 is confirmatory)

9. PLASMA ACTH ACTH – 10-50= Pituitary - 50-100 is pituitary or ectopic - >100 is ectopic ACTH is <10 is adrenal IMAGING – CT ADRENAL MRI WITH GADOLINIUM CONTRAST- PITUITARY PET SCAN- ECTOPIC

10. Management MRI CONTRAST:- -Pituitary adenoma >6mm -  TRANSPENOIDAL HYPOPHYSECTOMY ACTH sampling(Inferior petrosal sinus: peripheral) ratio done if . - <6mm adenoma - Hogh dose dexa suppression test - >= 50% suppression Ratio> 2 -  surgery High dose dexa suppression test- <50% suppression - Ectopic ( do a pet scan)

11. MRI – Shows no mass :- -CT ADRENALS- ADRENALECTOMY Adrenal enzyme inhibitors ( eg , metyrapone , cabergoline , pesiriotide , mitotane , ketoconazole) Glucocorticoid and potassium supplements Follow up – biochemical & MRI If persistent – Radiotherapy If due to steroid therapy – taper the dosage

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