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The HKU E-learning Platform in Clinical Medicine
The HKU E-learning Platform in Clinical Medicine
  • Physical Examination Skills
    • General Examination
    • Examination of the Cardiovascular System
    • Examination of the Gastrointestinal System
    • Examination of the Neurological System
    • Examination of the Respiratory System
    • Examination of the Musculoskeletal System
    • Demonstration on putting on a surgical/ N95 mask properly
  • eLearning Materials of Individual Divisions
    • Cardiology
    • Clinical Pharmacology
    • Dermatology
    • Endocrinology
    • Gastroenterology & Hepatology
    • Geriatrics
      • Common Physical Signs in the Geriatric Setting
      • Commonly used Assessments in the Geriatric Setting
    • Haematology
    • Infectious Diseases
    • Nephrology
      • General Nephrology
      • Imaging
      • Peritoneal Dialysis
      • Hemodialysis
    • Neurology
    • Rehabilitation Medicine
      • Modified Ashworth Scale
      • Complex Regional Pain Syndrome
      • Case 1
      • Case 2
    • Respiratory Medicine
    • Rheumatology
      • Common Rheumatological Cases
      • Clinical Signs and Radiographs of Patients with Rheumatological Disorders
  • Credits
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Endocrinology

Cushing’s Syndrome

December 8th, 2014

Cushing’s Syndrome

The left and middle photos are those on presentation,  while the photo on the right is post-surgery.

A middle-aged woman presented with worsening glycaemic control. On examination, she was noted to have Cushingoid features:

  • Moon face
  • Truncal obesity, relatively thin arms and legs
  • Wasting of limbs, bruising and proximal muscle weakness
  • Buffalo hump
  • Thinning of skin and purple striae over upper arms, thighs and abdomen

Other classical signs of Cushing’s syndrome

  • Pigmentation (in ACTH-dependent Cushing’s)

Diagnostic workup

  • Basal morning cortisol to exclude iatrogenic Cushing’s due to exogenous steroids
  • Basal 10pm cortisol to look for loss of diurnal rhythm
  • Screening tests for Cushing’s syndrome:
    • 1mg overnight dexamethasone suppression test for screening (normal suppression <50 nmol/L)
    • or 24 hour urine for free cortisol
    • Confirmatory test with 48-hour low dose dexamethasone suppression test (normal suppression <50 nmol/L)
    • Basal ACTH level to differentiate between adrenal cause (low ACTH) and ACTH-dependent Cushing’s syndrome (normal or high ACTH)
    • High dose dexamethasone suppression test and corticotrophin releasing factor stimulation test to differentiate between Cushing’s disease (pituitary cause) and ectopic ACTH
  • In ACTH-dependent Cushing’s syndrome:
    • MRI of pituitary gland in ACTH-dependent Cushing’s syndrome to look for pituitary adenoma
    • Inferior petrosal sinus sampling for ACTH to confirm and localize ACTH-producing pituitary adenoma
    • Search for underlying malignancy if suspected ectopic ACTH
  • In ACTH-independent Cushing’s syndrome:
    • CT or MRI adrenals in ACTH-independent Cushing’s syndrome

Other important investigations

Actively look for other possible complications of Cushing’s syndrome:

  • Hypertension
  • Glucose intolerance
  • Hypokalaemia
  • Osteoporosis
  • Opportunistic infection
  • Mental disturbances including irritability, depression and psychosis

Management

  • Trans-sphenoidal surgery for pituitary Cushing’s disease
  • Adrenalectomy for adrenal Cushing’s
  • Medical therapy including metyrapone and ketoconazole

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