Morning Report. Rick Hobbs PGY – 3.4ish. Frequency. Endogenous Cushing syndrome –13 cases per million individuals 70% to Cushing disease 15% to ectopic ACTH 15% to a primary adrenal tumor. Patient Characteristics.
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PGY – 3.4ish
Increased adipose tissue w/moon facies, buffalo hump, and supraclavicular fat pads
Central obesity w/ increased fat in mediastinum and peritoneum, and visceral fat on CT.
Increased waist-to-hip ratio greater than 1 in men and 0.8 in women
Violaceous striae on abdomen, buttocks, lower back, upper thighs, upper arms, and breasts
Telangiectasias and purpura.
Cutaneous atrophy with exposure of subcutaneous vasculature tissue and tenting of skin
Increased lanugo facial hair.
If glucocorticoid excess is accompanied by androgen excess, as occurs in adrenocortical carcinomas, hirsutism and male pattern balding may be present in women. Steroid acne over the face, chest, and back may be present
Acanthosis nigricans, which is associated with insulin resistance and hyperinsulinism, may be present. Axilla, elbows, neck, and under breasts.
Cardiovascular and renal
Hypertension and possibly edema may be present due to cortisol activation of the mineralocorticoid receptor leading to sodium and water retention.
Peptic ulceration particularly if patients are given high doses of glucocorticoids (rare in endogenous hypercortisolism).
Galactorrhea if anterior pituitary tumors compress the pituitary stalk, leading to elevated prolactin levels.
Signs of hypothyroidism if anterior pituitary tumor whose size interferes with proper TRH and TSH function
Decreased testicular volume due to low testosterone levels from inhibition of LHRH and LH/FSH function
Proximal muscle weakness
Osteoporosis w/ fractures, kyphosis, height loss, axial skeletal bone pain.
Avascular necrosis of the hip is also possible from glucocorticoid excess.
Emotional liability, fatigue, and depression.
Visual-field defects, often bitemporal hemianopsia, and blurred vision with large ACTH-producing pituitary tumors that impinge on the optic chiasma.
May occur in patients on steroids who stop taking their glucocorticoids or neglect to increase their steroids during an acute illness, or in patients who have recently undergone resection of an ACTH-producing or cortisol-producing tumor or who are taking adrenal steroid inhibitors.
Hypotension, abdominal pain, vomiting, and mental confusion (secondary to low serum sodium or hypotension). Hypoglycemia, hyperkalemia, hyponatremia, and metabolic acidosis.
Okay, that’s my patient, how do I find the source?