Snapshot A 42-year-old obese male who does not smoke, presents with diastolic hypertension. Physical exam shows a full, plethoric appearing face, increased facial hair, truncal obesity, and purple stria around the abdomen with scattered echymosis over the entire body. Labs show an HgB of 18 (12-16), a WBC of 18,000 (4,500-11,000) . The leukocyte differential shows and absolute neutrophillic leukocytosis and absolute lymphopenia and eosinopenia. CXR is normal. Introduction A condition that refers to the manifestations of hypercortisolism Iatragenic and pituitary adenoma are most common causes Cushings Syndrome Iatrogenic Cushings patients taking steroids is the most common cause of Cushings Syndrome. low ACTH Pituitary Cushings Pituitary Adenoma most common pathogenic cause (70%), the majority of adenomas are benign. high ACTH Cortisol responds to dexamethasone supression test Ectopic Cushings Small cell carcinoma of the lung. ectopic ACTH secretion extremely high ACTH Cortisol does not respond to dexamethasone supression test Adrenal Cushings Adrenal adenoma low ACTH Bilateral hyperplasia low ACTH Adrenal Carcinoma low ACTH Presentation Symptoms depression and psychological changes oligomenorrhea growth retardation weakness acne excessive hair growth symptoms of diabetes (polydipsia, polyuria, dysuria) Physical exam hypertension central obesity muscle wasting thin skin that easily bruises purple striae hirsutism moon facies buffalo hump Evaluation Labs screen for 24 hour free urinary cortisol as well as a serum cortisol level ACTH to localize lesion high dose dexamethasone supression test (localize ACTH high disease to pituitary) hyperglycemia hypokalemia and hypernatremia CT and MRI to localize lesions Inferior petrosal sinus sampling Differential Chronic alcoholism, depression, diabetes mellitus, adrenogenital syndrome Treatment Resection of source For non resectable tumors: ketoconazole (inhibits P450) aminoglutethimide (inhibits P450) metyrapone (blocks adrenal enzyme synthesis) mitotane (adenolytic)