CUSHING'S SYNDROME

DEFINITION

Cushing's syndrome, or Cushing syndrome is a collection of signs and symptoms caused by too much cortisol
hormone.

Cushing syndrome is caused by prolonged exposure to elevated levels of either endogenous glucocorticoids or
exogenous glucocorticoids.

CAUSES

1. The syndrome may result from excessive administration of corticosteroids or ACTH or from hyperplasia of the
adrenal cortex.
2. Cushing syndrome may be caused by taking too much corticosteroid medications, such as prednisone and
prednisolone. These drugs are used to treat conditions such as asthma and rheumatoid arthritis.
3. Other people develop Cushing syndrome because their bodies produce too much cortisol, a hormone normally
made in the adrenal gland. Causes of too much cortisol are:

 Cushing's disease, when the pituitary gland makes too much of the hormone ACTH. ACTH then signals the
adrenal glands to produce cortisol. Tumor of the pituitary gland may cause this condition.
 Tumor of the adrenal gland
 Tumor elsewhere in the body that produces cortisol (bronchogenic carcinoma)
 Tumors elsewhere in the body that produce ACTH (such as the pancreas, lung, and thyroid)

PATHOPHYSIOLOGY

 The hypothalamus is in the brain and the pituitary gland sits just below it.

 The paraventricular nucleus (PVN) of the hypothalamus releases corticotropin-releasing hormone (CRH), which
stimulates the pituitary gland to release adrenocorticotropin (ACTH).

 ACTH travels via the blood to the adrenal gland, where it stimulates the release of cortisol.

 Cortisol is secreted by the cortex of the adrenal gland from a region called the zona fasciculata in response to
ACTH. Elevated levels of cortisol exert negative feedback on the pituitary, which decreases the amount of ACTH
released from the pituitary gland.

 Strictly, Cushing's syndrome refers to excess cortisol of any etiology (as Syndrome means a group of symptoms).
One of the causes of Cushing's syndrome is a cortisol secreting adenoma in the cortex of the adrenal gland
(primary hypercortisolism/hypercorticism). The adenoma causes cortisol levels in the blood to be very high, and
negative feedback on the pituitary from the high cortisol levels causes ACTH levels to be very low.

 On the other hand, Cushing's disease refers only to hypercortisolism secondary to excess production of ACTH
from a corticotroph pituitary adenoma (secondary hypercortisolism/hypercorticism) or due to excess production
of hypothalamus CRH (Corticotropin releasing hormone) (tertiary hypercortisolism/hypercorticism). This causes
the blood ACTH levels to be elevated along with cortisol from the adrenal gland. The ACTH levels remain high
because the tumor is unresponsive to negative feedback from high cortisol levels.

CLINICAL MANIFESTATION

1. Blood sugar and white blood cell counts may be high. Potassium level may be low.

2. Laboratory tests that may be done to diagnose Cushing syndrome and identify the cause are:
 Serum cortisol levels
 Salivary cortisol levels
  Dexamethasone suppression test
 24-hour urine for cortisol and creatinine
 ACTH level
 ACTH (cosyntropin) stimulation test

3. Tests to determine the cause or complications may include:

 Abdominal CT
 ACTH test
 Pituitary MRI
 Bone density, as measured by dual x-ray absorptiometry (DEXA)

CLINICAL MANIFESTATION

 When overproduction of the adrenal cortical hormone occurs, arrest of growth, obesity, and musculoskeletal
changes occur along with glucose intolerance.
 The classic picture of Cushing’s syndrome in the adult 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. The patient complains
of weakness and lassitude. Sleep is disturbed because of altered diurnal secretion of cortisol.
 Excessive protein catabolism occurs, producing muscle wasting
 Osteoporosis. Kyphosis, backache, and compression fractures of the vertebrae may result.
 Retention of sodium and water occurs as a result of increased mineralocorticoid activity, producing hypertension
and heart failure.
 The patient develops a “moon-faced” appearance and may experience increased oiliness of the skin and acne.
 There is increased susceptibility to infection.
 Hyperglycemia or overt diabetes may develop.
 The patient may also report weight gain, slow healing of minor cuts, and bruises.
 In females of all ages, virilisation may occur as a result of excess androgens. Virilization is characterized by the
appearance of masculine traits and the recession of feminine traits.
 There is an excessive growth of hair on the face (hirsutism), the breasts atrophy, menses cease and
the voice deepens.
 Libido is lost in men and women.
 Changes occur in mood and mental activity; psychosis may develop.
 Distress and depression are common and are increased by the severity of the physical changes that occur with this
syndrome.
 If Cushing’s syndrome is a consequence of pituitary tumor, visual disturbances may occur because of pressure of
the growing tumor on the optic chiasm.

MEDICAL MANAGEMENT

1. If Cushing’s syndrome is caused by pituitary tumors rather than tumors of the adrenal cortex,

 Surgical removal of the tumor by transsphenoidal hypophysectomy is the treatment of choice and has a 90%
success rate
 Radiation of the pituitary gland
2. Adrenalectomy is the treatment of choice in patients with primary adrenal hypertrophy.
3. Postoperatively, symptoms of adrenal insufficiency may begin to appear 12 to 48 hours after surgery because of
reduction of the high levels of circulating adrenal hormones. Temporary replacement therapy with hydrocortisone may be
necessary for several months until the adrenal glands begin to respond normally to the body’s needs. If both adrenal
glands have been removed (bilateral adrenalectomy), lifetime replacement of adrenal cortex hormones is necessary.
4. Adrenal enzyme inhibitors (eg, metyrapone, aminoglutethimide, mitotane, ketoconazole) may be used to reduce
hyperadrenalism if the syndrome is caused by ectopic ACTH secretion by a tumor.
5. If Cushing’s syndrome is a result of the administration of corticosteroids, an attempt is made to reduce or taper the
medication to the minimum dosage needed to treat the underlying disease process (eg, autoimmune and allergic diseases
and rejection of transplanted organs).

NURSING MANAGEMENT
ASSESSMENT
 Diabetes mellitus.
 Muscle weakness and loss of muscle mass.
 Hypertension.
 Redistribution of fat.
 Poor wound healing.
 Emotional lability.
 Insomnia.
 Rounded “moon face”
 Fatty “Buffalo Hump” between shoulders
 Truncal obesity
 Hirsutism (excess facial hair)
 Acne, Petechiae
 Skin becomes susceptible to trauma, infection,
 bruising, edema
 Wounds are slow to heal
 Osteoporosis
 High Blood Pressure
 Assess patients knowledge of Cushing’s Syndrome and therapy and their willingness to
learn
 Assess patient for changes in physical appearance caused by the glucocorticoid excess
 Assess patients feeling about the changes in appearance and their coping mechanisms

NURSING DIAGNOSIS

1. Risk for infection related to altered protein metabolism and inflammatory response
 Assess patient frequently for signs of infection such as an increase in temperature.
 Have the patient avoid others with infection.
 Check the mouth, lungs, and skin for early signs of infection.
2. Risk for injury related to weakness
 Increase calcium, vitamin D and protein in diet
 Assess skin for signs of bruising, breakdown, wounds not healing, changes in height
 Instruct patient about safety measures to reduce risk for falls and injury
3. Self-care deficit related to weakness, fatigue, and muscle wasting
 Assess the patient’s ability to perform self-care activities.
 Encourage moderate activity.
 Patient should be reassured that symptoms will subside with treatment.
 Help patient plan rest periods throughout the day.
4. •Disturbed body image related to changes in physical appearance and decreased activity
 Reassure patient that physical changes are a result of the increased hormone levels and will most likely
resolve when those levels return to normal
 Promote coping methods to help patient deal with changes in appearance, clothing and grooming
 Assist patient in locating a support group
5. Impaired skin integrity related to thin and fragile skin and impaired healing
 Assess patient’s skin.
 Avoid using adhesive tape.
  Encourage and assist the patient to change positions frequently to prevent skin breakdown.
6. Disturbed thought process related to mood swings, irritability and depression