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{{Cushing's syndrome}}
{{Cushing's syndrome}}


{{CMG}} {{MMF}}
{{CMG}} {{AE}} {{MMF}}


==Overview==
==Overview==
When Cushing's is suspected, either a [[dexamethasone suppression test]] (administration of dexamethasone and frequent determination of cortisol and ACTH level), or a 24-hour urinary measurement for cortisol offer equal detection rates.<ref>Raff H, Findling JW. ''A physiologic approach to the diagnosis of the Cushing's syndrome.'' Ann Intern Med 2003;138:980-91. PMID 12809455</ref> Dexamethasone is a [[glucocorticoid]] and simulates the effects of cortisol, including [[negative feedback]] on the [[pituitary gland]]. When dexamethasone is administered and a blood sample is tested, high cortisol would be indicative of Cushing's syndrome.
When Cushing's syndrome is suspected, either a [[dexamethasone suppression test]] (administration of [[dexamethasone]] and frequent determination of [[cortisol]] and [[ACTH]] level) or a 24-hour urinary measurement for [[cortisol]] offer equal detection rates. [[Dexamethasone]] is a [[glucocorticoid]] and simulates the effects of [[cortisol]], including [[negative feedback]] on the [[pituitary gland]]. When [[dexamethasone]] is administered and a blood sample is tested, high [[cortisol]] would be indicative of Cushing's syndrome.
A novel approach, recently cleared by the US FDA, is sampling cortisol in [[saliva]] over 24 hours, which may be equally sensitive, as late night levels of salivary cortisol are high in Cushingoid patients. Other pituitary hormone levels may need to be ascertained.
A novel approach, recently cleared by the US FDA, is sampling cortisol in [[saliva]] over 24 hours, which may be equally sensitive, as late night levels of salivary [[cortisol]] are high in Cushingoid patients. Other pituitary hormone levels may need to be ascertained.


==Laboratory Findings==
==Laboratory Findings==
===Diagnosis of hyercortisolism===
The laboratory findings associated with Cushing's syndrome are:<ref>Raff H, Findling JW. ''A physiologic approach to the diagnosis of the Cushing's syndrome.'' Ann Intern Med 2003;138:980-91. PMID 12809455</ref>
Hypercortisolism can be established by any of the following tests:
===Diagnosis of hypercortisolism===
*24 hr urine cortisol
[[Hypercortisolism]] can be established by any of the following tests:
*Midnight salivary cortisol
*24-hour urine [[cortisol]]
*Low dose dexamethasone suppression test; high cortisol level after the dexamethasone test is suggestive of hypercortisolism.
*Midnight salivary [[cortisol]]
*Low dose [[dexamethasone]] suppression test; high [[cortisol]] level after the [[dexamethasone]] test is suggestive of [[hypercortisolism]].
===Tests to establish the cause of hypercortisolism===
===Tests to establish the cause of hypercortisolism===
*Measure Adrenocorticotrophic hormone (ACTH) levels.
*Measure [[Adrenocorticotrophic hormone|Adrenocorticotrophic hormone (ACTH)]] levels.
*If ACTH is less than 5 pg/dl, perform an adrenal CT scan or MRI to search for possible adrenal causes.
*If [[ACTH]] is less than 5 pg/dl, perform an [[CT scan|adrenal CT scan]] or [[MRI]] to search for possible adrenal causes.
*If ACTH is higher than 5 pg/dl Corticotrophic releasing hormone (CRH) test also called desmopressin test can be used to differentiate between cushing disease and ectopic ACTH secretion.  
*If [[ACTH]] is higher than 5 pg/dl [[Corticotrophic|Corticotrophic releasing hormone (CRH)]] test also called [[desmopressin]] test can be used to differentiate between Cushing disease and ectopic ACTH secretion.  
 
===Approach to the diagnosis of Cushing's syndrome===
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{{familytree  | | | | | | | | | | | | A01 | | | | | |A01=24 hr urine [[cortisol]] or midnight salivary [[cortisol]] shows [[hypercortisolism]] }}
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{{familytree  | | | | | |!| | | | | | |!| | | | | | |!| | }}
{{familytree  | | | | | |!| | | | | | |!| | | | | | |!| | }}
{{familytree  | | | | | |!| | | | | | |!| | | | | | |!| | | }}
{{familytree  | | | | | |!| | | | | | |!| | | | | | |!| | | }}
{{familytree  | | | | | D01 | | | | | D02 | | | | |D03 |D01=ACTH independent Cushing syndrome|D02=CRH (desmopressin) test|D03=ACTH dependent Cushing syndrome}}
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{{familytree  | | | | | |!| | | ||,|-|^|-|.| | | | |!|}}
{{familytree  | | | | | |!| | | ||!||||!| | | | |!| }}
{{familytree  | | | | | |!| | | ||!||||!| | | | |!| }}
{{familytree  | | | | | |!| | | | |!| | | |!| | | | |!| }}
{{familytree  | | | | | |!| | | | |!| | | |!| | | | |!| }}
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{{familytree  | | | | | E01 | | |E05 | | E02 | | | E03 |E01=[[Adrenal]] [[CT]]/[[MRI]]|E02=Evaluate as [[ACTH]] dependent Cushing syndrome if there is an [[ACTH]] response|E03=[[Corticotrophic|Corticotrophic releasing hormone (CRH)]] ([[desmopressin]]) AND high dose [[dexamethasone]] suppression test OR [[MRI]] brain|E05=Evaluate as [[ACTH]] independent Cushing syndrome if NO [[ACTH]] response}}
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{{familytree  | | | | | | | | | | | | | | | | F01 | | | | | F02 | | | |F01=Adequate stimulation and suppression|F02=Mixed or negative response}}
{{familytree  | | | | | | | | | | | | | | | | F01 | | | | | F02 | | | |F01=Adequate stimulation and suppression OR [[pituitarty]] mass >6mm|F02=Mixed/negative response OR no [[pituitary]] mass OR mass < 6mm}}
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{{familytree  | | | | | | | | | | | | | | | | G01 | | | | | G02 | | | |G01=Cushing disease|G02=Inferior petrosal sinus sampling}}
{{familytree  | | | | | | | | | | | | | | | | G01 | | | | | G02 | | | |G01=Cushing disease|G02=Inferior petrosal sinus sampling}}
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{{familytree  | | | | | | | | | | | | | | | | | || | ||!| | | |!| }}
{{familytree  | | | | | | | | | | | | | | | | | || | ||!| | | |!| }}
{{familytree  | | | | | | | | | | | | | | | | | | ||| H01 || H02 | | | |H01=Cushing disease if step-up in ACTH|H02=Ectopic ACTH secretion if no step-up in ACTH}}
{{familytree  | | | | | | | | | | | | | | | | | | ||| H01 || H02 | | | |H01=Cushing disease if step-up in [[ACTH]]|H02=Ectopic [[ACTH]] secretion if no step-up in [[ACTH]]}}
{{familytree/end}}
{{familytree/end}}
===Other Laboratory findings===
*Hypokalemia


==References==
==References==

Latest revision as of 20:42, 20 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

When Cushing's syndrome is suspected, either a dexamethasone suppression test (administration of dexamethasone and frequent determination of cortisol and ACTH level) or a 24-hour urinary measurement for cortisol offer equal detection rates. Dexamethasone is a glucocorticoid and simulates the effects of cortisol, including negative feedback on the pituitary gland. When dexamethasone is administered and a blood sample is tested, high cortisol would be indicative of Cushing's syndrome. A novel approach, recently cleared by the US FDA, is sampling cortisol in saliva over 24 hours, which may be equally sensitive, as late night levels of salivary cortisol are high in Cushingoid patients. Other pituitary hormone levels may need to be ascertained.

Laboratory Findings

The laboratory findings associated with Cushing's syndrome are:[1]

Diagnosis of hypercortisolism

Hypercortisolism can be established by any of the following tests:

Tests to establish the cause of hypercortisolism

Approach to the diagnosis of Cushing's syndrome

 
 
 
 
 
 
 
 
 
 
 
24 hr urine cortisol or midnight salivary cortisol shows hypercortisolism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure serum ACTH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<5pg/ml
 
 
 
 
5-20pg/dl
 
 
 
 
>20pg/dl
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ACTH independent Cushing syndrome
 
 
 
 
Corticotrophic releasing hormone (CRH) (desmopressin) test
 
 
 
 
ACTH dependent Cushing syndrome
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adrenal CT/MRI
 
 
Evaluate as ACTH independent Cushing syndrome if NO ACTH response
 
Evaluate as ACTH dependent Cushing syndrome if there is an ACTH response
 
 
Corticotrophic releasing hormone (CRH) (desmopressin) AND high dose dexamethasone suppression test OR MRI brain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adequate stimulation and suppression OR pituitarty mass >6mm
 
 
 
 
Mixed/negative response OR no pituitary mass OR mass < 6mm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cushing disease
 
 
 
 
Inferior petrosal sinus sampling
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cushing disease if step-up in ACTHEctopic ACTH secretion if no step-up in ACTH
 
 
 

Other Laboratory findings

  • Hypokalemia

References

  1. Raff H, Findling JW. A physiologic approach to the diagnosis of the Cushing's syndrome. Ann Intern Med 2003;138:980-91. PMID 12809455


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