Cushing’s syndrome Zhaoxiaojuan

Effects of glucocorticoid Effects on metabolism Effects on immunologic function and inflammatory Effects on musculoskeletal and connective tissues Effects on fluid and electrolyte homeostasis Neuropsychiatric and behavioral effects Gastrointestinal effects Developmental effects

Clinical features Obesity (The increased fat distribution is not generalized) Moon-shaped face and plethoric Purple striae Hypertension IGT Osteoporosis Hypokalemic alkalosis

Suspected Cushing’s synd. Plasma cortisol  Urinary free cortisol  Urinary 17-OHCS  Low dose dexamethasone suppression test 2.0mg/day  2days >50% reduce from basal<50% reduce from basal NORMAL Cushing’s Synd. High dose dexamethasone suppression test 8.0mg/day  2days <50% reduce from basal >50% reduce from basal Probable Cushing’s Disease Adrenal Disease Ectopic ACTH Synd. Suspected Cushing’s synd. Plasma ACTH 

Adrenal Disease Ectopic ACTH Synd Plasma ACTH IncreasedLow Probable Ectopic ACTH Synd.Probable Adrenal Disease Tumor SearchCT /MRI Scan of Adrenals positivenegative ECTOPIC ACTH SYNDROME normaladrenal mass Consider Adrenonodular Hyperplasia, Other Disorders urinary 17-KS Plasma DHEA 17-KS  DHEA  ADRENAL CARCINOMA DHEA   17-KS   ADRENAL ADENOMA

Nyctohemeral rhythm Neural stimuli CRH ACTH Cortisol  Cortisol (CBG bound) (free) Physiological and Metabolic effects Negative feedback Plasma Hypothalamus Anterior pituitary Adrenal cortex Inactivation by reduction and conjugation Liver Unchanged cortisol (measured as urinary free cortisol) Tetrahydrocortisol Tetrahydrocortisone Cortols,Cortolones (measurd as urinary 17-OHCS) Urine The hypothalamic-pituitary-adrenal axis

hypothalamus pituitary adrenal Drugs: Cyproheptadine Metergoline Bromocryptine Adrenalectomy Surgery: Transsphenoidal microsurgery Radiation: 60 Co linear accelerator Drug: o,p’DDD(mitotane) Metyrapone Aninoglutethmide ketokonazole CRH ACTH CS Surgery Radiation TREATMENT