Cushing's syndrome differential diagnosis: Difference between revisions
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* When secondary to medications, the excessive hair is of new onset, and other features of virilization, such as acne and deepened voice, may be present | * When secondary to medications, the excessive hair is of new onset, and other features of virilization, such as acne and deepened voice, may be present | ||
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Cushing's syndrome must be differentiated from other adrenal tumors such as [[adrenocortical adenoma]], adrenal [[metastasis]], and [[Pheochromocytoma|adrenal medullary tumors]]. | |||
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! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}} | |||
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Clinical picture}} | |||
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Imagings}} | |||
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Laboratory tests}} | |||
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |'''Adrenocortica'''l carcinoma | |||
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* Mass effect symptoms | |||
* Symptoms related to excess [[glucocorticoid]] | |||
* Symptoms related to excess [[mineralocorticoid]] | |||
* Symptoms related to excess [[androgen]] or [[estrogen]] secretion | |||
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* Irregular shape | |||
* Non-[[homogeneous]] density because of central areas of low attenuation due to [[tumor]] [[necrosis]] | |||
* [[Tumor]] [[calcification]] | |||
* Diameter usually >4 cm | |||
* Unilateral location | |||
* High unenhanced [[Computed tomography|CT]] attenuation values (>20 HU) | |||
* Non-[[homogeneous]] enhancement on [[Computed tomography|CT]] with [[intravenous]] [[Contrast medium|contrast]] | |||
* Delay in [[contrast medium]] washout (10 minutes after administration of [[contrast]], an absolute [[contrast medium]] washout of less than 50 percent) | |||
* Hypointensity compared with [[liver]] on T1 weighted [[Magnetic resonance imaging|MRI]] and high to intermediate signal intensity on T2 weighted [[Magnetic resonance imaging|MRI]] | |||
* High standardized uptake value (SUV) on [[FDG-PET|FDG]]-[[PET scan|PET-CT]] study | |||
* Evidence of local [[invasion]] or [[Metastasis|metastases]] | |||
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* [[Androgen|Adrenal androgens]] ([[DHEAS|DHEAS)]] | |||
* [[Androstenedione]] | |||
* Bioavailable [[testosterone]] should be measured in every patient. | |||
* [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] | |||
* Serum [[estradiol]] in men and postmenopausal women | |||
* [[Cortisol level]] | |||
* Fasting serum [[cortisol]] at 8 AM following a 1 mg dose of [[dexamethasone]] at bedtime | |||
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Adrenal adenoma]] | |||
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* Symptoms related to excess [[glucocorticoid]] | |||
* Symptoms related to excess [[mineralocorticoid]] | |||
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* Round, [[homogeneous]] with sharp margination | |||
* Unilateral with diameter less than 4 cm | |||
* Low unenhanced [[Computed tomography|CT]] attenuation values (<10 HU) | |||
* Rapid [[contrast medium]] washout after administration of contrast | |||
* An absolute [[contrast medium]] washout of more than 50 percent | |||
* [[Chemical shift]]: evidence of [[lipid]] on [[Magnetic resonance imaging|MRI]] | |||
* Isointensity with [[liver]] on both T1 and T2 weighted [[Magnetic resonance imaging|MRI]] sequences | |||
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* [[Cortisol level]] | |||
* Fasting [[serum]] [[cortisol]] at 8 AM following a 1 mg dose of [[dexamethasone]] at bedtime | |||
* [[Renin]] ([[Plasma renin activity|PRA]]) or plasma renin concentration (PRC): very low in patients with [[primary aldosteronism]], usually less than 1 ng/mL per hour for [[Plasma renin activity|PRA]] and usually undetectable for PRC<ref name="pmid26372319">{{cite journal| author=Manolopoulou J, Fischer E, Dietz A, Diederich S, Holmes D, Junnila R et al.| title=Clinical validation for the aldosterone-to-renin ratio and aldosterone suppression testing using simultaneous fully automated chemiluminescence immunoassays. | journal=J Hypertens | year= 2015 | volume= 33 | issue= 12 | pages= 2500-11 | pmid=26372319 | doi=10.1097/HJH.0000000000000727 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26372319 }}</ref> | |||
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Cushing's syndrome]] | |||
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* Rapid [[Obesity|weight gain]], particularly of the [[trunk]] and [[face]] with [[limbs]] sparing ([[central obesity]]) | |||
* Proximal [[muscle weakness]] | |||
* A [[round face]] often referred to as a "[[moon face]]" | |||
* Excess [[sweating]] | |||
* [[Headache]] | |||
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* Imaging may show [[mass]] if presents | |||
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* 24-hour [[urine]] [[cortisol]] | |||
* Midnight salivary [[cortisol]] | |||
* Low-dose [[dexamethasone]] suppression test; high [[cortisol]] level after the [[dexamethasone]] test is suggestive of [[hypercortisolism]]. | |||
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Pheochromocytoma]] | |||
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* [[Palpitations]] especially in [[Epinephrine|epinephrine-]]<nowiki/>producing [[Tumor|tumors]]. | |||
* [[Anxiety]] often resembling that of a [[panic attack]] | |||
* [[Sweating]] | |||
* [[Headaches]] occur in 90 % of patients. | |||
* Paroxysmal attacks of [[hypertension]] but some patients have normal [[blood pressure]]. | |||
* It may be [[asymptomatic]] and discovered incidentally after [[Screening (medicine)|screening]] for [[MEN, type 2|MEN]] patients. | |||
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* Increased [[attenuation]] on non-enhanced [[Computed tomography|CT]] (>20 HU) | |||
* Increased [[mass]] [[vascularity]] | |||
* Delay in [[contrast medium]] washout (10 minutes after administration of [[contrast]], an absolute [[contrast medium]] washout of less than 50 percent) | |||
* High signal intensity on T2 weighted [[Magnetic resonance imaging|MRI]] | |||
* [[Cystic]] and [[hemorrhagic]] changes | |||
* Variable size and may be [[bilateral]] | |||
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* [[Plasma]] fractionated [[Metanephrine|metanephrines]] | |||
* 24-hour [[urinary]] fractionated [[Metanephrine|metanephrines]] | |||
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Adrenal metastasis]] | |||
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* [[Symptoms]] and [[signs]] of primary [[malignancy]] especially [[lung cancer]] | |||
* General constitutional symptoms: | |||
**[[Fever]] | |||
**[[Fatigue]] | |||
**[[Weight loss]] | |||
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* Irregular shape and non-[[homogeneous]] nature | |||
* Tendency to be [[bilateral]] | |||
* High un-enhanced [[Computed tomography|CT]] [[attenuation]] values (>20 HU) and enhancement with [[Contrast medium|intravenous contrast]] on [[Computed tomography|CT]] | |||
* Delay in [[contrast medium]] washout (10 minutes after administration of contrast, an absolute [[contrast medium]] washout of less than 50 percent) | |||
* Isointensity or slightly less intense than the [[liver]] on T1 weighted [[Magnetic resonance imaging|MRI]] and high to intermediate signal intensity on T2 weighted [[Magnetic resonance imaging|MRI]] (representing an increased water content) | |||
* Elevated standardized uptake value on [[FDG-PET|FDG]]-[[PET scan]] | |||
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==References== | ==References== |
Revision as of 15:33, 17 October 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Furqan M M. M.B.B.S[2]
Overview
Cushing's syndrome must be differentiated from other diseases that cause hypertension, obesity, and hyperandrogenism, such as Metabolic syndrome X and pseudo-Cushing's syndrome.
Differentiating Cushing's syndrome from Other Diseases
The table below summarizes the findings that differentiate Cushing's disease from other conditions that may cause hypertension, hyperandrogenism, and obesity. Facial plethora, skin changes, osteoporosis, nephrolithiasis and neuropsychiatric conditions should raise the concern for Cushing's syndrome.[1][2][3][4]
Other differentialsCushing's syndrome must be differentiated from diseases that cause virilization and hirsutism in female:[5][6][7]
Less common differentialsCushing's syndrome should also be differentiated from other causes of hyperprolactinemia that may present as galactorrhea, amenorrhea, (in females) and infertility (in both males and females) including:
Cushing's syndrome must be differentiated from other adrenal tumors such as adrenocortical adenoma, adrenal metastasis, and adrenal medullary tumors.
References
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