Cushing's syndrome for medical students especially for Pharma students.

1. || JSR ||
Prepared by :

2. Cushing’s Syndrome :
Hyper secretion of cortisol hormone for a long time by Zona fasciculata
of Adrenal gland.
Functions of cortisol :
Regulate BPRegulate BP
Reduces Inflammation
Keep Heart and blood vessels functioning normally
Helps the body respond to stress
Regulates the conversion of carbohydrates , proteins and fats into usable energy.

3. Contents :
Aetiology
Symptoms
Diagnosis
Treatment

4. Aetiology :
1. Medications
2. Over production of cortisol
3. Pituitary gland tumor
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4. ACTH-Secreting tumor
5. Primary adrenal gland disease
6. Familial cushing syndrome

5. 1. Medications :
Take oral corticosteroid medications in high doses over a extended period of time.
Take higher doses of following :
- Repeated injectable corticosteroids- Repeated injectable corticosteroids
- inhaled steroid medicines
- steroid skin creams
2. Over production of cortisol :
Cortisol is excessively produced due to either over activity of
one / both adrenal glands or over production of ACTH.
ACTH Adreno cortico tropic hormone ( secretes by pituitary gland ).

6. 3. Pituitary gland tumor :
Benign ( non-cancerous tumor ) of pituitary gland produces excess amount of ACTH
This excess ACTH stimulates adrenal glands to make more cortisol .
4. ACTH – Secreting tumor :4. ACTH – Secreting tumor :
Tumor develops in an organ that normally does not secrete ACTH , will begin to
Secrete ACTH in excess .
The tumor may be either malignant or benign
The tumor normally found in lungs , pancreas , thyroid and thymus.

7. 5.Primary adrenal gland disease :
Disorders of adrenal glands such as –
- adrenocortical carcinomas
( cancerous tumors of adrenal cortex )
- benign tumors on glands- benign tumors on glands
- nodular enlargement of glands
Above all leads to increase the cortisol secretion from adrenal gland
Here, the release of cortisol doesn’t depend on stimulation from ACTH.

8. 6. Familial cushing syndrome :
People inherit a tendency to develop tumors on
one or more of their endocrine glands
Affect cortisol levels
Cortisol secretion

9. Symptoms :
 Fatty tissue deposits
- Around the mid section and upper back
- in the face ( moon face )
- Between the shoulders ( buffalo hump )
 Pink or purple stretch marks on the skin of
- Abdomen
- thighs
- breasts
- arms

10.  Thinning and fragile skin
 Slow healing of cuts , insect bites and infections
 Depression , anxiety and irritability
 Loss of emotional control
 Cognitive difficulties
 Increase pigmentation on skin
 Impaired growth in children
 Several fatigue & acne
 Muscle weakness
 Bone loss leads to fractures over time ( osteoporosis )

11.  High BP
 Headache
 Type – 2 diabetes ( occasionally )
 Decrease libido
 Decrease fertility
In men
 Erectile dysfunction
 Irregular or absent menstrual periods
 Thicker or more visible body hair & facial hair
( Hirsutism ) .
In women

12. Diagnosis :
1. Physical exam
2. Urine and blood tests
3. Saliva test
4. Imaging tests
5. Petrosal sinus sampling

13. 1. Physical exam :
Doctor observes following
- moon face
- buffalo hump
- thin skin with bruises and stretch marks- thin skin with bruises and stretch marks
2. Urine and blood tests :
To measure the cortisol levels in urine and blood.

14. 3.Saliva test :
 Cortisol levels normally rise and fall throughout the day
 Cortisol levels drop significantly in the evening in normal people
 Take sample of person’s saliva late at night and measure the cortisol levels
 If cortisol levels are too high , it indicates cushing’s syndrome . If cortisol levels are too high , it indicates cushing’s syndrome .
4. Imaging tests :
CT scan and MRI scan provides images of pituitary and adrenal glands
To detect any tumors .

15. 5. Petrosal sinus sampling :
 This test can help determine whether the cause of endogenous
cushing’s syndrome is rooted in the pituitary gland or somewhere else
 A thin tube inserts into the upper thigh or groin area while you’re
sedated and is threaded to the petrosal sinuses
 Measure the ACTH levels from the petrosal sinuses and from
a blood sample taken from the forearm
 If ACTH levels are higher in sinus sample than in forearm , it indicates
that the problem occurs in the pituitary gland
 If ACTH levels are similar between the sinus sample and forearm ,
root problem lies outside of pituitary gland.

16. Treatment :
1. Medications
2. Reduce corticosteroid use
3. Surgery
4. Radiation therapy
5. Bilateral adrenalectomy

17. Ketoconazole
Mitotane ( lysodren )
Metyrapone ( metopirone )
control excess
production of cortisol
1. Medications :
Mifepristone is administered to the people with cushing’s syndrome and
type – 2 diabetes
-Mifepristone doesn’t decrease the cortisol production but it blocks the
effect of cortisol on body tissues.

18. Pasireotide ( signifor ) - decreases the ACTH production from pituitary
tumor and it’s given as a injection twice/day
2. Reduce corticosteroid use :
Doctor prescribe non-corticosteroid drugs to reduce the
dosage of corticosteroidsdosage of corticosteroids
Don’t stop either taking corticosteroids or reduce the dose of corticosteroids
unless otherwise told by the doctor.

19. 3.Surgery :
If tumor is present on - lungs
- pancreas
- adrenal glands
- pituitary gland ,
then surgeon remove those tumors.then surgeon remove those tumors.
After the operation, you will need to take cortisol replacement
medications to provide your body with correct amount of cortisol.

20. 4. Radiation therapy :
Radiation can be given in small doses over a 6 week period initially with a
technique called STEREOTACTIC RADIOSURGERY
Later, a large one time dose of radiation is delivered to tumor and minimizeLater, a large one time dose of radiation is delivered to tumor and minimize
the radiation exposure to surrounding tissues.

21. 5. Bilateral adrenalectomy :
Adrenal gland is removed surgically
It inhibits the excess production of cortisol
You will have to take life-long replacement medications .You will have to take life-long replacement medications .

22. VRS