Physiology
Endocrine
A 70 year old woman with known rheumatoid arthritis complains of weight gain, muscle weakness and ankle swelling. She has resistant hypertension. Which of the following is the most likely diagnosis:
Answer:
Clinical features of Cushing's syndrome:- Plethoric moon face
- Central obesity
- Impaired glucose tolerance or diabetes
- Hypertension
- Menstrual irregularity, erectile dysfunction
- Osteoporosis and kyphosis
- Purple striae and tendency to bruise easily
- Proximal myopathy
- Hirsutism and frontal alopecia
- Ankle oedema
- Interscapular fat pad
- Acne
- Musculoskeletal aches and pains
- Depression
- Poor wound healing
- Polycythaemia
Cushing's Syndrome
Physiology / Endocrine / Adrenal Function
Last Updated: 21st April 2019
Cushing's syndrome is the name given to the clinical symptoms and signs induced by chronic glucocorticoid excess.
Cushing's disease refers to the specific condition of excess corticosteroids as a result of an ACTH-secreting pituitary adenoma, leading to bilateral adrenal hyperplasia and excess cortisol secretion. Cushing's disease is also associated with hyperpigmentation due to the melanocyte-stimulating action of ACTH.
Causes
This may occur due to:
- Excess secretion of ACTH
- ACTH secreting pituitary adenoma (Cushing's disease)
- Ectopic ACTH e.g. lung cancer
- Excess secretion of cortisol
- Adrenal adenoma or carcinoma
- Exogenous steroids
Clinical Features
- Plethoric moon face
- Central obesity
- Impaired glucose tolerance or diabetes
- Hypertension
- Menstrual irregularity, erectile dysfunction
- Osteoporosis and kyphosis
- Purple striae and tendency to bruise easily
- Proximal myopathy
- Hirsutism and frontal alopecia
- Ankle oedema
- Interscapular fat pad
- Acne
- Musculoskeletal aches and pains
- Depression
- Poor wound healing
- Polycythaemia
![By Mikael Häggström (Own work) [CC0], via Wikimedia Commons](https://mrcemsuccess.com/wp-content/uploads/2017/10/Cushings_syndrome_vector_image.svg_.png)
Clinical Features of Cushing's Syndrome. (Image by Mikael Häggström (Own work) [CC0], via Wikimedia Commons)
Management
If an adrenal tumour is found, adrenalectomy is the treatment of choice. In ectopic ACTH, appropriate treatment of the underlying malignancy and medical control of cortisol levels are needed. In Cushing's disease, trans-sphenoidal removal of the pituitary adenoma is indicated. Medical treatment (e.g. metyrapone which blocks cortisol production) can be used pre-operatively if symptoms are severe, or there is uncontrolled hypokalaemia, diabetes and hypertension.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
