Why Is This Diagnosis So Difficult
Cushing’s disease is rare. Mild cases can be hard to detect. No two people with Cushing’s disease are exactly alikesigns and symptoms are not the same.
May be mistaken as other more common conditions. These include weight problems caused by poor diet and/or lack of exercise, poorly controlled diabetes, polycystic ovary syndrome , pregnancy, depression or other mental health disorders, or alcoholism.
A pituitary tumor, the underlying cause of Cushing’s disease, is often small and hard to find.
What Are The Signs And Symptoms Of Cushings Syndrome
The appearance of people with Cushings syndrome starts to change as cortisol levels build up. Regardless of what kind of tumor they have or where the tumor is located, people tend to put on weight in the upper body and abdomen, with their arms and legs remaining thin their face grows rounder they develop fat around the neck and purple or pink stretch marks appear on the abdomen, thighs, buttocks or arms. Individuals with the syndrome usually experience one or more of the following symptoms: fatigue, muscle weakness, high glucose levels, anxiety, depression, and high blood pressure. Women are more likely than men to develop Cushings syndrome, and when they do they may have excess hair growth, irregular or absent periods, and decreased fertility.
Cushing’s Disease And Negative Mri
Patients with Cushings disease often present with a negative MRI study, showing no evidence of tumor. Inferior petrosal sinus sampling is mandatory to confirm that the source of ACTH production is the pituitary gland.
The first step is these cases is to make sure the MRI study is of high-quality, as frequently patients do not obtain the best possible imaging. At Stanford Pituitary Center we have developed with our expert neuroradiologists the best possible imaging protocol to maximize chances of microadenoma identification this includes a 1-mm fine-cut T1 sequences with and without contrast in all 3 spatial planes, dynamic sequences, and a flair post-contrast sequence.
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Cushings Syndrome And Cushing Disease
Cushing syndrome is a disorder with physical and mental changes that result from having too much cortisol in the blood for a long period of time. There are two types of Cushing syndrome: exogenous and endogenous . The symptoms for both are the same. The only difference is the causes.
Cushing disease is a rare condition, only affecting 10 to 15 people per million every year. It is more common in women and occurs most often in people between the ages of 20 and 50.
A pituitary adenoma is the most common cause of Cushing disease. An adenoma is a pituitary tumor that is almost always benign. The tumors can be hard to diagnose because they are quite small. Having an endocrinologist help with the diagnostic process can improve the chances of a prompt, successful diagnosis for patients who have symptoms of Cushing disease.
Endocrine Connection
Cortisol is a hormone produced by the adrenal glands that is directly connected to the bodys stress response. Most cells within the body have cortisol receptors. Secretion of the hormone is controlled by the hypothalamus, the pituitary gland, and the adrenal gland, a combination gland often referred to as the HPA axis. In a healthy individual, it releases adrenocorticotropic hormone , a hormone produced in the pituitary gland, and stimulates the production and release of cortisol by the adrenal glands. In normal amounts, cortisol helps the body:
Cushings Disease Vs Cushings Syndromethe Cortisol Connection Complications And Cures
Affecting only about 10 to 15 people per million every year, the rare condition, Cushings Disease can wreak havoc on the body, causing a multitude of uncomfortable and sometimes debilitating symptoms. Cushings disease is different from Cushings syndrome however.
Cushings Syndrome vs. Cushings DiseaseWhats the difference?
Though sometimes mistakenly used interchangeably, Cushings syndrome and Cushings disease are two different diagnoses.
Cushings syndrome refers to the diagnosed medical condition of elevated cortisol levels in the body. This encompasses all causes for the increased values.
In the case of Cushings disease however, abnormal cells collect in the pituitary gland and form a tumor. This tumor releases excessive amounts of ACTH . In direct response, the adrenal glands overproduce cortisol.
What are the symptoms of Cushings syndrome/disease?
Individuals with Cushings syndrome or Cushings disease may experience:
- Weight gain/obesity in the torso
- Pronounced red stretch marks on the skin
- Neurological problems
Other Cushings disease symptoms may include:
- Hump on the back of the neck due to excess fat on the back of the neck
- Thin arms and legs
- Redness of face and cheeks
- Psychiatric issues
Symptoms specific to women include menstrual cycle irregularities and facial/body hair growth. Men may experience erectile dysfunction, low libido, and decreased fertility.
Complications Associated with Cushings Syndrome
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What Tests Will Be Done To Diagnose Cushings Syndrome
Your healthcare provider will likely order several tests including:
Once your healthcare provider has confirmed that you have Cushings syndrome, the next step is to determine why. Often it is medication or a tumor. If youre on glucocorticoids, that is probably the cause, and your healthcare provider will likely decrease the dosage. If youre not on glucocorticoids, that indicates there is a likely a tumor in your adrenal glands, pituitary gland or elsewhere. Your healthcare provider may recommend the following imaging studies to reveal the location of the tumor:
What Are The Longer
Following successful treatment of Cushings syndrome, it may take between several weeks and a couple of years for the changes due to excessive cortisol production to return to normal and for the symptoms to disappear. Muscle and bone strength will improve, but some patients, particularly post-menopausal women, may need treatment for osteoporosis. Blood pressure and blood sugar should be closely monitored.
Patients may need to take hydrocortisone replacement tablets for life. Higher doses of hydrocortisone must be supplied for medical emergencies as the body is unable to make its own cortisol in response to stressful situations. Patients should also carry an hydrocortisone injection in case of emergency, a steroid card, and wear Medic-Alert jewellery.
It is important to recognise that even after treatment for Cushings syndrome, some patients do not regain their original quality of life, or it can take many months or years. The amount of investigations, treatment and follow-up means that genuine diagnosis of Cushings is very time consuming for the patient and their relatives.
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Causes Of Cushings Syndrome
The symptoms of Cushings syndrome are caused by damage to body tissues due to high levels of the hormone cortisol in the blood over a long time. The disorders that trigger high cortisol levels include:
- Tumour of the pituitary gland
- Tumour of the adrenal gland
- ACTH-producing tumours elsewhere in the body
- Multiple endocrine neoplasia 1
- Glucocorticoid hormone therapy.
When Should I See My Healthcare Provider
See your healthcare provider if you have the following symptoms of Cushings syndrome:
Symptoms that affect females specifically include:
- New or excessive facial hair.
- A change in libido .
- A change in the menstrual cycle.
Symptoms that affect males and females include:
- Rapid weight gain in the face , abdomen, the back of the neck and chest.
- A red, round face.
- Purple stretch marks over the abdomen.
- Easy bruising on the arms and legs.
- General weakness and tiredness .
- Blurry vision and dizziness.
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Screening Tests For Cushing Disease/syndrome
- Blood tests: We can measure the levels of ACTH and cortisol in your blood. We take a blood sample in the morning because hormone levels change throughout the day.
- Urine tests: We can measure cortisol in your urine. We may ask for multiple samples. Ask your doctor if any of your current medications could affect results.
- Late-night saliva test: We look at cortisol in your saliva. Youll collect several samples just before midnight, when cortisol usually drops to its lowest level. A high level can indicate Cushing disease/syndrome.
What Are Normal Cortisol Levels
The level of cortisol in your blood, urine and saliva normally peaks in the early morning and declines throughout the day, reaching its lowest level around midnight. This pattern can change if you work a night shift and sleep at different times of the day.
For most tests that measure cortisol levels in your blood, the normal ranges are:
- 6 a.m. to 8 a.m.: 10 to 20 micrograms per deciliter .
- Around 4 p.m.: 3 to 10 mcg/dL.
Normal ranges can vary from lab to lab, time to time and person to person. If you need to get a cortisol level test, your healthcare provider will interpret your results and let you know if you need to get further testing.
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Role Of Cortisol: The Stress Hormone
My cortisol levels were too high. I couldn’t keep my anxiety under control. Sometimes I would sleep for 20 minutes, sometimes 2 days.
To better understand Cushing’s disease, it helps to understand cortisol. A naturally occurring hormone, cortisol is often referred to as the stress hormone. Under normal circumstances, it is released in times of stress and illness. Cortisol also helps to maintain many systems in the body, such as blood pressure, blood sugar levels, bone formation, and the sleep/wake cycle. Cortisol plays an important role in how the body uses fats, proteins, and carbohydrates.
Not Being Heard Keep Talking
It is important to advocate for yourselfmeaning, keep talking to your doctors and those around you about what you are experiencing. You know your own body best, so don’t be afraid to speak up about what is wrong. The sooner you are diagnosed, the better chance of addressing the more serious symptoms of Cushing’s disease and improving your quality of life.
Steps you can take if you think you may have Cushing’s disease:Find an endocrinologist, especially one that specializes in pituitary diseases. Keep a detailed list of your symptoms and show it to your doctor. Take pictures of yourself to your appointment to show what you looked like before you started experiencing symptoms. Advocate for yourselfkeep talking until you are heard!
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Physical Findings & Clinical Presentation
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Hypertension
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Central obesity with rounding of the facies thin extremities.Fig. 1 illustrates the distribution of adipose tissue in Cushing syndrome
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Hirsutism, menstrual irregularities, hypogonadism
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Skin fragility, ecchymoses, red-purple abdominal striae , acne, poor wound healing, hair loss, facial plethora, hyperpigmentation . The frequency of individual findings in Cushing syndrome is summarized inTable 1
FIG. E2. Clinical features of Cushing syndrome.
A, Centripetal and some generalized obesity and dorsal kyphosis in a 30-yr-old woman with Cushing disease.B, Same patient as inA showing moon facies, plethora, hirsutism, and enlarged supraclavicular fat pads.C, Facial rounding, hirsutism, and acne in a 14-yr-old girl with Cushing disease.D, Central and generalized obesity and moon facies in a 14-yr-old boy with Cushing disease.E andF, Typical centripetal obesity with livid abdominal striae seen in a 41-yr-old woman and a 40-yr-old man with Cushing syndrome.G, Striae in a 24-yr-old patient with congenital adrenal hyperplasia treated with excessive doses of dexamethasone as replacement therapy.H, Typical bruising and thin skin of a patient with Cushing syndrome. In this case, the bruising occurred without obvious injury.
Williams textbook of endocrinology,
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Muscle wasting with proximal myopathy
R.J. Auchus, in, 2014
Inferior Petrosal Sinus Sampling
In some cases, MRI fails to identify an abnormality. If your doctor suspects Cushing’s disease, he or she may order super-selective inferior petrosal sinus sampling .
IPSS must be performed by an experienced interventional neuroradiologist because it carries risk, and if done inappropriately, can give misleading results.
The inferior petrosal sinuses are veins that occur on both sides of the pituitary gland.
- Blood leaving the right half of the pituitary gland drains into the right inferior petrosal sinus and vice versa.
- Specially trained interventional neuroradiologists can thread a tiny catheter into the inferior petrosal sinus. Blood samples are then taken from each sinus and from a vein just below the heart.
If the ACTH level is the same in the inferior petrosal sinus compared to the vein below the heart, this suggests that a tumor somewhere else in the body is producing ACTH.
In Cushing’s disease, the ACTH level in the inferior petrosal sinus is much higher compared to the vein below the heart
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Multiple Endocrine Neoplasia 1
The pituitary, pancreas, adrenals, thyroid and parathyroid glands belong to the endocrine system. MEN1 is an inherited condition characterised by tumours on at least two of these glands. If the pituitary or adrenals are affected, Cushings syndrome can result.Primary pigmented micronodular adrenal disease occurs in children and young adults, where there is an increase in the number of cortisol-producing adrenal tumours.
Confirming A Cushing Diagnosis
Dexamethasone suppression/corticotropin-releasing hormone stimulation test : If screening tests show high ACTH/cortisol levels, we may use this blood test to confirm the diagnosis. We give you medications to lower or raise certain hormones. This helps us see if symptoms are from Cushing disease/syndrome or a condition such as depression, stress, kidney failure or alcoholism.
Inferior petrosal and cavernous sinus sampling: If tests indicate that high ACTH is causing Cushing, well find out if the problem is from your pituitary gland or some other part of your body . Well insert thin tubes called catheters into areas alongside your pituitary gland. Well monitor your ACTH levels during the test. If your pituitary gland is the source, well arrange for you to consult with a neurosurgeon. For ectopic Cushing syndrome, well work with other OHSU specialists for further treatment.
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Adrenal Glands Producing Too Much Cortisol
Cortisol is a hormone, which means it is made in one part of your body but causes an effect in another part. Cortisol is made by your adrenal glands, which sit on top of your kidneys.Image: 123RFToo much cortisol is produced if you have a tumour in your adrenal glands, pituitary gland or, occasionally, elsewhere in your body, e.g. your lungs.
Who Is More Likely To Have Cushings Syndrome
Cushings syndrome most often affects adults, usually aged 30 to 50,1 but can also occur in children. Cushings syndrome affects about three times as many women as men.2 In people who have type 2 diabetes and blood glucose levels that stay too high over time, along with high blood pressure, Cushings syndrome may be the cause. People who take medicines called glucocorticoids, which are similar to cortisol, also can develop Cushings syndrome. This type of Cushings syndrome is called exogenous. More than 10 million Americans take glucocorticoids each year,3 but its not known how many of them develop Cushings syndrome.
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Whats The Difference Between Cushing Syndrome And Cushing Disease
Both illnesses come from too much cortisol in the body.
In Cushing syndrome , excess cortisol can come from outside or inside the body. For example, it can come from using corticosteroid medications, such as prednisone. Or it can come from a pituitary or adrenal tumor causing the body to make too much cortisol.
Cushing disease is a specific type of Cushing syndrome. It occurs when a pituitary tumor causes the body to make too much cortisol. Cushing disease is the most common form of endogenous Cushing syndrome, and makes up about 70% of Cushing syndrome cases.
What Are The Symptoms Of Cushings Syndrome
Signs and symptoms of Cushing’s syndrome vary. People who have very high levels of cortisol for a long time are likely to have clear signs of the disorder, including
- increased fat around the base of the neck
- a fatty hump between the shoulders
- wide purple stretch marks, mainly on the abdomen, breasts, hips, and under the arms
Children with Cushings syndrome tend to have obesity and grow more slowly than other children. Women may have excess hair on their face, neck, chest, abdomen, and thighs. Menstrual periods may become irregular or stop. Men may have decreased fertility with lowered interest in sex and may have erectile dysfunction.
Not everyone with Cushings syndrome has these symptoms, which can make it hard to detect.
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Symptoms Of Cushings Syndrome
Some of the symptoms include:
- Weight gain around the abdomen, and obesity
- Wasting of the limbs
- A buffalo hump of fat high on the back
- Round, red and puffy-looking face
- Thin skin, easily bruised, slow healing and ulcers
- Muscular weakness
- High white blood cell count, low serum potassium
- High blood sugar
- Mood swings, irritability, anxiety, depression
- Irregular menstrual periods or no menstrual periods
- Increased facial hair in women
- Weakened bones, susceptibility to bone fractures , osteoporosis and backache
- Susceptibility to pneumonia and TB.
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How Common Is Cushings Syndrome
The most common form of Cushings syndrome is the exogenous form, i.e. due to the patient taking an excess of steroid medication. Endogenous Cushings syndrome is rarer and is estimated to affect 1 in 500,000 adults per year. Of these, 85% have pituitary-dependent Cushings syndrome, 10% have adrenal Cushings and 5% have ectopic adrenocorticotropic hormone production .