Cushing syndrome is due to the effects of excessive glucocorticoids which may be exogenous or endogenous.
Cushing disease refers to glucocorticoid excess solely due to an adrenocorticotropic hormone-secreting pituitary adenoma, while Cushing syndrome encompasses all aetiologies of glucocorticoid excess 6.
Typically, patients have the following clinical features 6:
- rounded face, sometimes described as 'moon-shaped'
- progressive centripetal obesity and weight gain
- prominent supraclavicular fat pad, sometimes known as a 'buffalo hump'
- purple skin striae
- easy skin bruising
- acanthosis nigricans
- proximal myopathy
- depression and other mood disorders
- hyperglycaemia and development of overt diabetes mellitus
- immunosuppression and recurrent infections
Female patients with Cushing syndrome may also have signs of androgen excess (e.g. hirsutism, acne, changes in libido, virilisation) and menstrual changes 6. Features of androgen excess are not present in men as the adrenal glands are not a major source of androgens in men 6.
Furthermore, certain patient groups may demonstrate additional or atypical clinical features depending on the aetiology of Cushing syndrome 6:
- patients with Cushing disease:
- hyperpigmentation, because melanocyte-stimulating hormone (MSH) and adrenocorticotropic hormone (ACTH) share the same precursor molecule, proopiomelanocortin (POMC)
- clinical features as a resultant of an intracranial mass (see: pituitary adenoma)
- patients with ectopic ACTH secretion (e.g. secondary to small cell lung cancer):
- hyperpigmentation, because ACTH has an alpha MSH sub-unit as part of its structure
- patients with an adrenal carcinoma:
Endogenous sources of excess cortisol production include:
- adrenal adenoma: 20%
- primary pigmented nodular adrenal dysplasia (PPNAD): rare 2
- ACTH-secreting tumour: 80%
- adrenocorticotropin (ACTH)-independent macronodular adrenocortical hyperplasia (AIMAH): rare cause of ACTH-independent Cushing syndrome 4
- corticotropin-releasing hormone-secreting tumour: very rare
- hypothalamic tumours
- ectopic production
The workup of Cushing syndrome requires measurement both of cortisol as well as ACTH. Measuring cortisol typically needs to be over a 24 hour period because release is intermittent.
Imaging of the suspected region is then required:
If ACTH is elevated but no microadenoma can be identified, and no ectopic source can be found, then inferior petrosal sinus sampling can be undertaken. Bilateral adrenal hyperplasia is one of the most common findings on abdominal CT.
ACTH secreting pituitary microadenomas may be unapparent on imaging in 40-50% of cases.
Treatment and prognosis
Management depends on the specific aetiology 6.
- bilateral adrenalectomy in a patient with Cushing disease can lead to the development of Nelson syndrome
History and etymology
It is named after Harvey Williams Cushing (1869-1939), a pioneering American neurosurgeon, who first described a patient with hypercorticism 7.
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- 4. Doppman JL, Chrousos GP, Papanicolaou DA et-al. Adrenocorticotropin-independent macronodular adrenal hyperplasia: an uncommon cause of primary adrenal hypercortisolism. Radiology. 2000;216 (3): 797-802. Radiology (full text) - Pubmed citation
- 5. Grainger & Allison's Diagnostic Radiology: 2-Volume Set, 6e. Churchill Livingstone. ISBN:0702042951. Read it at Google Books - Find it at Amazon
- 6. Fauci AS. Harrison's principles of internal medicine. New York: McGraw-Hill, Medical Publishing Division; 2008.
- 7. Cushing H. The Pituitary Body and Its Disorders. (1912) ISBN: 9781331948223