Internal Diseases and Therapy · MU Sofia

85. Hypercorticism

Explains the pathway from hypothalamic CRH through pituitary ACTH to adrenal cortisol, then separates Cushing's syndrome, meaning any glucocorticoid excess, from Cushing's disease, a pituitary adenoma. It lists the main clinical features, the dexamethasone suppression and urinary cortisol tests, and how ACTH levels help localise the lesion. Management covers surgical resection and mifepristone when surgery is not viable.

Inside: 1 section · 3 labelled pictures · 14 flashcards · 2 min

Topic 86 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 1 section, about 274 words (2 min of reading), with 14 flashcards.

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  1. Hypercorticism

Hypercorticism

Corticotropin releasing hormone is released from the hypothalamus, it goes to act on the anterior pituitary where it triggers release of Adrenocorticotropic hormone (ACTH). ACTH then acts directly on the adrenal glands, stimulating the adrenals to produce cortisol hormone.

So, hypercorticism = cushing's syndrome which is not the same as cushing’s disease. Cushing's syndrome describes the state of glucocorticoid excess, causes of which include adrenal causes (adenomas, carcinomas), ectopic production of ACTH and CRH and iatrogenic causes. Meanwhile, Cushing’s disease refers only to a pituitary adenoma that causes excess production of ACTH (it accounts for 60-70% of Cushing syndrome cases).

The symptoms of Cushing’s disease and Cushing Syndrome are the same, even if the mechanism is different, the main symptoms are listed below:

  • Headache
  • Moon face
  • Buffalo hump
  • Psychological disturbance (depression, anxiety, irritability etc)
  • Generalized malaise, glucose intolerance, weight gain and weakness
  • Thinning skin, fragility, acne, hirsutism, striae
  • hypertension
  • Increased fracture risk
  • Irregular periods/erectile dysfunction

Diagnosis can be confirmed with the following tests:

  • 1mg overnight dexamethasone suppression test - give at 11pm measure cortisol at 8am, normally cortisol would be <50nmol/L, failure to suppress indicates cushing syndrome of any aetiology
  • OR 24 hour free urinary cortisol
  • To localise the lesion
  • If ACTH levels are low, adrenal pathology is likely (think adrenal adenoma)
  • If ACTH is high, likely pituitary source, think cushing disease (if >50% suppression on dexamethasone test), or ectopic ACTH secretion (if<50% suppression on dexamethasone test)

Management

  • If pituitary adenoma (cushing disease) offer trans-sphenoidal surgical resection first line and glucocorticoid support
  • If cause is ectopic tumour, again, surgical removal
  • Finally, mifepristone (a glucocorticoid receptor antagonist) may be used if surgery is not viable

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