• A 46 y/o man present with fever, red
tender area on his right leg, consistent
• His recent medical history reveals
fatigue, easy bruising and wt. gain in the
past 6 months.
• His family history is negative for DM and
• physical examination shows central
obesity (BMI 32.5 kg/m2, waist
circumference 115 cm)
• BP 160/104
• Moon face appearance, a dorsal fat pad
in the neck and abdominal purple striae.
4. What is Cushing’s syndrome?
• Cushing syndrome is caused by prolonged exposure to elevated levels of
either endogenous glucocorticoids or exogenous glucocorticoids.
• Due to primary
• Following the
5. Cushing’s syndrome VS Cushing’s disease ?
• Cushing’s syndrome :
- clinical state of increased free
- Spontaneous Cushing’s
• Cushing’s Disease:
- ACTH dependent
hypercorticism , pituitary
- it is the most common cause of
7. Radiological investigations
It should be performed after the biochemical laboratory evaluation has
It’s used to determine the cause or complications.
Adrenal CT or
Pituitary MRI Chest X-ray
8. Adrenal CT or MRI:
• Adrenal adenomas and
carcinomas are relatively large
and can be detected by CT scan
9. Pituitary MRI
• A pituitary adenoma can be seen
but it is often small and not
visible in a significant proportion
10. Chest X-ray
• It is used in patients with
suspected ectopic ACTH
• The ACTH-secreting tumors are
often oat-cell carcinomas of the
lung (bronchus carcinoma).
• Successful treatment of Cushing’s syndrome should lead to reversal of the
presenting clinical features.
• However, untreated Cushing’s syndrome has a very bad prognosis, with
death from: hypertension, MI, infection and heart failure.
• Whatever the underlying cause, cortisol hypersecretion should be
controlled prior to surgery or radiotherapy.
14. Pharmacotherapy (Cushing’s syndrome)
• The goal of pharmacotherapy is to reduce morbidity and prevent
• bind and activate human
resulting in inhibition of
ACTH secretion, which
leads to decreased
0.6-0.9 twice daily
• These agents either
inhibit the synthesis of
750 mg – 4 g daily , in 3-4
• Ketoconazole :200 mg
three times daily
15. Surgery and radiotherapy (Cushing’s disease)
removal of the
16. Trans-sphenoidal removal of the tumor
• Is the treatment of choice.
• Result in remission of 75-80% of
• But the results vary considerably.
• Experienced surgeon is essential.
17. Bilateral adrenalectomy
• It’s an effective last resort if other
measures fail to control the
• The patient will need
replacement therapy after
surgery, and possibly continued
19. Cushing’s syndrome due to other causes.
- should be resected after
achievement of clinical remission
- are highly aggressive and has
- if there’s no widespread
metastases, tumor bulk should be
- adrenolytic drug mitotane may
inhibit the growth of the tumor
and prolonged survival.
- radiotherapy can be used.
• A 46 y/o man present with fatigue, easy bruising and wt. gain
• The patient had moon face appearance, a dorsal fat pad in the neck and
abdominal purple striae.
• The diagnostic tests reveals that the patient has Cushing's syndrome.
• The patient will initially manage the cortisol levels by taking metyrapone
4 gm/ 3 daily, Ketoconazole, 200 mg /3 daily
• Further treatment decided based on the specific etiology.
• Kumar & Clarks, Clinical Medicine ,
eighth edition (2012).
• Up to date : Cushing's syndrome.
• Up to date : Cushing's syndrome
treatment (Beyond the Basics)
• Emedicine : medscape: Cushing’s
This is an important point , we will use it in the treatment.
What do you think is used for? Endogenous or exo
Or abdominal CT
بازيريوتايد , ميتايرابونalso it’s used in cushung’s disease.
Pituitary dependant hyperadrenalism
he pituitary is located at the base of the brain. It is possible to access this area through the gums above the upper front teeth or the noseUsing special instruments, the surgeon makes an incision in one of these areas (figure 2). The incision is extended through the sphenoid sinus, allowing the surgeon to see and remove the adenoma with an endoscope (a thin, lighted tube with a camera)