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Pathology
Cortisol excess from exogenous or endogenous source
Aetiology
Exogenous
Steroids: Usually iatrogenic
Pseudo-Cushing’s: ETOH excess, depression
Endogenous
ACTH Dependant (ACTH)
Pituitary adenoma secreting ACTH (Cushing’s disease)
Ectopic ACTH secretion: e.g. small-cell lung cancer, carcinoid.
Presents with hyperpigmentation, hypokalaemic alkalosis, weight loss
ACTH independent (ACTH)
Adrenal adenoma or carcinoma
Signs
Central obesity, easy bruising, proximal myopathy, thin shiny skin, painful purple striae, oedema, virilisation-excess hair, deep voice, coarse skin osteoporosis
Symptoms
Fluid retention, weight gain, tiredness, depression, headaches
Investigations
Bloods: FBC, U&E, LFTs, glucose, High or Low dexamethasone suppression test,
Urine: 24 hour urinary free cortisol
Imaging: Inferior petrosal sinus sampling (central: peripheral ACTH 4:1),
Pituitary MRI, CT Chest, Abdomen and Pelvis
Treatment
Medical: Gradual weaning of exogenous steroids, treat hypertension or raised
glucose, bone protection
Surgical: Removal of pituitary tumour, excision of ectopic source, bilateral
adrenalectomy (ACTH dependant when source not identified).
Prognosis
Good prognosis if cured but if poorly controlled complications of vascular disease and diabetes. Adrenal carcinoma has a poor prognosis
Relapse, osteoporosis, recurrent infections, metabolic complications, panhypopituitarism, Nelson’s syndrome (aggressive corticotroph tumour post bilateral adrenalectomy in pituitary Cushing’s), diabetes
Key Facts
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Key Images
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Key References
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