Notes on Cushing's syndrome

1. CUSHING’S SYNDROME
NABIRYE MIRIA 2017/U/NSM/005/P

2. CUSHING’S SYNDROME
• Cushing’s syndrome (Cushing's disease, hypercortisolism, adrenal hyper
function) is a cluster of clinical abnormalities caused by excessive levels of
adrenocortical hormones (particularly cortisol) or related corticosteroids
and, to a lesser extent, androgens and aldosterone.
• The prognosis depends on the underlying cause; it’s poor in untreated
people and in those with untreatable ectopic corticotrophin-producing
carcinoma.
• Cushing’s syndrome results from excessive, rather than deficient,
adrenocortical activity.
• The syndrome may result from excessive administration of corticosteroids
or ACTH or from hyperplasia of the adrenal cortex.

3. Functions of cortisol hormone
• Regulate your blood pressure
• Reduces inflammation.
• Cortisol helps your body respond to stress.
• It also regulates the metabolism of proteins, carbohydrates and fats in
your diet into usable energy.

4. Statistics and Incidences
• Incidences of Cushing syndrome are already common
worldwide.
• Cushing’s syndrome affects 13 of every 1 million people.
• It is more common in women than in men and occurs
primarily between ages 25 and 40.

5. Causes (endogenous and exogenous)
• Excess of cortisol hormone In approximately 70% of patients,
Cushing’s syndrome results from excessive production of
corticotropin and consequent hyperplasia of the adrenal cortex.
• Tumor. In the remaining 30% of the patients, Cushing’s syndrome
results from a cortisol-secreting adrenal tumor, which is usually
benign.(ACTH tumors)
• A primary adrenal gland disease.
• Familial Cushing syndrome. Rarely, people inherit a tendency to
develop tumors on one or more of their endocrine glands, affecting
cortisol levels and causing Cushing syndrome.

6. PATHOPHYSIOLOGY
• Cushing’s syndrome is commonly caused by use of
corticosteroid medications and is infrequently due to
excessive corticosteroid production by the adrenal cortex
(Tierney et al., 2001).
• However, overproduction of endogenous corticosteroids
may be caused by several mechanisms, including a tumor of
the pituitary gland that produces ACTH and stimulates the
adrenal cortex to increase its hormone secretion despite
adequate amounts being produced.

7. CONT.
• Primary hyperplasia of the adrenal glands in the absence of a
pituitary tumor is less common.
• Another less common cause of Cushing’s syndrome is the
ectopic production of ACTH by malignancies; bronchogenic
carcinoma is the most common type of these malignancies.
Regardless of the cause, the normal feedback mechanisms
that control the function of the adrenal cortex become
ineffective, and the usual diurnal pattern of cortisol is lost.

8. Clinical manifestations
• Muscle weakness. Muscle weakness is due to hypokalemia
or a loss of muscle mass from increased catabolism.
• Buffalo hump. Buffalo hump is one of the symptoms
included in the Cushing’s triad, and these are fat pads over
the upper back.
• Moon face. Moon face is a symptom included in the
Cushing’s triad and are recognized as excess fats over the
face.
• Truncal obesity. Fat pads throughout the trunk refers to
truncal obesity, one of the symptoms in Cushing’ triad

9. cont.
• Peptic ulcer results from increased gastric production and pepsin
secretion, and decreased gastric mucus.
• Irritability and emotional lability ranges from euphoric behavior
to depression and psychosis.
• Hypertension occurs due to sodium and water retention.
• Compromised immune system. Increased susceptibility to infection
due to decreased lymphocyte production and suppressed antibody
formation
• Abdominal striae
• hirtusim

10. Endocrine/Metab
olic
Truncal obesity, Moon face, Buffalo hump, Sodium
retention, Hypokalemia, Metabolic alkalosis,
Hyperglycemia, Menstrual irregularities, Impotence,
Negative nitrogen balance, Altered calcium
metabolism, Adrenal suppression
Immune Function Decreased inflammatory
responses
Impaired wound healing
Increased susceptibility to
infections
Cardiovascular Hypertension
Heart failure
Clinical manifestations per system

11. Skeletal Osteoporosis, Spontaneous fractures, Aseptic
necrosis of femur, Vertebral compression,
fractures
Gastrointestinal Peptic ulcer, Pancreatitis
Muscular Myopathy, Muscle weakness
Dermatologic Thinning of skin, Petechiae, Ecchymoses,
Striae, Acne
Psychiatric Mood alterations, Psychoses
Clinical manifestations per system

12. Clinical Manifestations
• The classic picture of Cushing’s syndrome
• In the adults there is that of central-type obesity, with a fatty
“buffalo hump” in the neck and supraclavicular areas, a
heavy trunk, and relatively thin extremities.
• The skin is thin, fragile, and easily traumatized; ecchymoses
(bruises) and striae develop
• Sleep is disturbed because of altered diurnal secretion of
cortisol.

13. Cont.
Signs and symptoms women with Cushing syndrome may experience
• Thicker or more visible body and facial hair (hirsutism)
• Irregular or absent menstrual periods
Signs and symptoms men with Cushing syndrome may experience
• Decreased libido
• Decreased fertility
• Erectile dysfunction

14. Complications
• Addisonian crisis. The patient with Cushing’s syndrome whose
symptoms are treated by withdrawal of corticosteroids, by
adrenalectomy, or by removal of a pituitary tumor is at risk for
adrenal hypofunction and addisonian crisis.
• Bone loss (osteoporosis), which can result in unusual bone fractures,
such as rib fractures and fractures of the bones in the feet
• High blood pressure (hypertension)
• Type 2 diabetes
• Frequent or unusual infections
• Loss of muscle mass and strength

15. Patients at risk
• Patients going for organ transplant
• Patients with neurological conditions

16. Diagnosis
• Low-dose dexamethasone suppression test. Dexamethasone (1 mg) is
administered orally at 11pm, and a plasma cortisol level is obtained at
8am the next morning, and this usually confirms the diagnosis of
Cushing’s syndrome. Suppression of cortisol to less than 5 mg/dL
indicates that the hypothalamic-pituitary-adrenal axis is functioning
properly
• Stimulation test. In a stimulation test, administration of metyrapone,
which blocks cortisol production by the adrenal glands, tests the
ability of the pituitary gland and hypothalamus to detect and correct
low levels of plasma cortisol by increasing corticotropin production.

17. CONT.
• Imaging studies. Ultrasound, CT scan, or angiography localizes adrenal
tumors and may identify pituitary tumors.
• Electrolyte levels. A patient with Cushing’s syndrome include an
increase in serum sodium and a decrease in potassium levels.
• Blood studies. Indicators of Cushing’s syndrome include an increase in
the blood glucose levels, a reduction in the number of eosinophils,
and disappearance of lymphoid tissue.

18. management
• Pituitary irradiation. Patients with pituitary-dependent Cushing’s syndrome
with adrenal hyperplasia and severe cushingoid symptoms (such as
psychosis, poorly controlled diabetes mellitus, osteoporosis, and severe
pathologic fractures) may require pituitary irradiation.
• Adrenal enzyme inhibitors. Metyrapone, aminoglutethimide, mitotane,
and ketoconazole may be used to reduce hyperadrenalism if the syndrome
is caused by ectopic ACTH secretion by a tumor that cannot be eradicated.
• Cortisol therapy. Cortisol therapy is essential during and after surgery, to
help the patient tolerate the physiologic stress imposed by the removal of
the pituitary or adrenals.

19. CONT.
• Transsphenoidal hypophysectomy. Surgical removal of the tumor by
transsphenoidal hypophysectomy is the treatment of choice if
Cushing’s syndrome is caused by pituitary tumors and has an 80%
success rate.
• Adrenalectomy. Adrenalectomy is the treatment of choice in patients
with primary adrenal hypertrophy.

20. Nursing concerns
• Body image
• Body weakness
• Reduced immunity

21. ASSESSMENT
• Health history. The history includes information about the
patient’s level of activity and ability to carry out routine
and self-care activities.
• Physical exam. The skin is observed and assessed for trauma,
infection, breakdown, bruising, and edema.
• Mental function. The nurse assesses the patient’s mental
function including mood, responses to questions, awareness
of environment, and level of depression.

22. NUURSING DIAGNOSIS
• Risk for injury related to weakness.
• Risk for infection related to altered protein metabolism and inflammatory
response.
• Self-care deficit related to weakness, fatigue, muscle wasting, and
altered sleep patterns.
• Impaired skin integrity related to edema, weight gain, impaired healing,
and thin and fragile skin.
• Disturbed body image related to altered physical appearance, impaired
sexual functioning, and decreased activity level.
• Disturbed thought processes related to mood swings, irritability, and
depression.

23. NURSING
DIAGNOSIS
Disturbed body image related to altered physical appearance, impaired
sexual functioning, and decreased activity level.
GOAL Patient will have an improved body image
INTERVENTIONS Discuss the impact that changes have had on patient’s self-concept and
relationships with others. Major physical changes will disappear in time if
the cause of Cushing syndrome can be treated.
Weight gain and edema may be modified by a low-carbohydrate, low-
sodium diet; a high-protein intake can reduce some bothersome
symptoms.
EVALUATION Patient had improved body image

24. NURSING DIAGNOSIS Risk for injury related to weakness.
GOAL Patient will have no injury
INTERVENTIONS Provide a protective environment to prevent
falls, fractures, and other injuries to bones and soft
tissues.
Assist the patient who is weak in ambulating to
prevent falls or colliding into furniture.
Recommend foods high in protein, calcium, and
vitamin D to minimize muscle wasting and osteoporosis;
refer to dietitian for assistance.
EVALUATION Patient had no injury

25. NUSING
DIAGNOSIS
Impaired skin integrity related to edema,
impaired healing, and thin and fragile skin.
GOAL Patient will maintain skin integrity
INTERVENTIONS Avoid adhesive tape, which can tear and irritate the
skin.
Assess skin and bony prominences frequently.
Encourage and assist patient to change
positions frequently.
EVALUATION Patient maintained skin integrity