Cushing Syndrome

Best Practice & Research Clinical Endocrinology & Metabolism 34 (2020) 101380
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Best Practice & Research Clinical

Endocrinology & Metabolism
journal homepage: www.elsevier.com/locate/beem
Cushing's syndrome: Overview of clinical

presentation, diagnostic tools and complications
Mattia Barbot, MD *, Marialuisa Zilio, MD, Carla Scaroni, MD
Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Italy
a r t i c l e i n f o
Cushing's syndrome (CS) is a severe condition that results from
Article history: chronic exposure to elevated circulating cortisol levels; it is a rare
Available online 30 January 2020 but potentially life-threating condition, especially when not timely
diagnosed and treated. Even though the diagnosis can be
Keywords: straightforward in florid cases due to their typical phenotype,
Cushing's syndrome milder forms can be missed. Despite the availability of different
incidence screening tests, the diagnosis remains challenging as none of the
complications available tools proved to be fully accurate. Due to the ubiquitous
cortisol effect of cortisol, it is easy understandable that its excess leads to a
variety of systemic complications including hypertension, meta-
bolic syndrome, bone damages and neurocognitive impairment.
This article discusses clinical presentation of CS with an eye on the
most frequent cortisol-related comorbidities and discuss the main
pitfalls of first- and second-line tests in endogenous hyper-
cortisolism diagnostic workup.
© 2020 Elsevier Ltd. All rights reserved.
Introduction
Cushing's syndrome (CS) is a rare condition due to prolonged exposure to high circulating cortisol
levels. The most common cause of CS is the exogenous administration of glucocorticoids (GCs), mainly
assumed for chronic disorders such as asthma, chronic obstructive pulmunary disease and rheuma-
tological conditions; it should be recalled that almost 1% of general population has taken GC therapy for
a period longer than 3 months [1]. Conversely, endogenous CS is a rare condition with an estimated
annual incidence of 2e3 cases/1000000 [2]. The pathogenetic mechanisms of endogenous CS can be
* Corresponding author. Endocrinology Unit, Department of Medicine DIMED, Via Ospedale Civile, 105 e 35128, Padova, Italy.
E-mail address: mattiabarbot85@gmail.com (M. Barbot).
https://doi.org/10.1016/j.beem.2020.101380
1521-690X/© 2020 Elsevier Ltd. All rights reserved.
2 M. Barbot et al. / Best Practice & Research Clinical Endocrinology & Metabolism 34 (2020) 101380
divided into ACTH-dependent (80% of cases, from a pituitary or other ectopic tumor) and ACTH-
independent (20% of cases, due to autonomous adrenal overproduction of cortisol that can depend
on either benign or malignant nodules, or by bilateral primary micro- and macronodular adrenocor-
tical hyperplasia) [3]. ACTH-secreting pituitary adenoma is the cause of about 70% of all cases of CS and
is termed Cushing's disease (CD). Reported incidence of CD ranges from 1.2 to 2.4 per million people per
year in newly diagnosed cases, with a prevalence of 1.2e5.6% of all pituitary tumors [2,4,5]. It is a
condition affecting prevalently female patients (female:male ratio of 3e4:1) in their fertile age, with a
peak of incidence in the 3rd-4th decade of life. The incidence of other causes of CS is 0.6 per million
people per year for adrenal adenoma and 0.2 per million people per year for adrenal carcinoma [1]. In
approximately 20% of ACTH-dependent CS, the source of ACTH secretion is ectopic, mainly produced by
neuroendocrine tumors of the lung or more rarely thyroid, thymus and pancreas. ACTH-independent
CS accounts for about 20% of CS cases and most of the time is due to unilateral adrenal adenoma (15%)
or carcinoma (5%); more rarely, it is caused by primary bilateral macronodular adrenal hyperplasia
(BMAH) or primary pigmented nodular adrenocortical disease (PPNAD) and its non-pigmented variant
(either as isolated disease or as part of Carney complex) [6]. In childhood and adolescence CS is even
rarer, but of particular interest for its consequences and the possibility of underlying genetic condi-
tions. Even in this clinical setting, CD remains the most common cause of endogenous hyper-
cortisolism, mainly due to the presence of a microadenoma, with apparently no gender preference [7].
The development of CS in the first 5 years of life is usually associated with McCune-Albright syn-
drome, a rare sporadic disorder caused by activating mutations of Arg201 in the guanine-nucleotide-
binding protein (G protein) a subunit that carries nodular adrenocortical hyperplasia associated with
other endocrine impairments such as hyperthyroidism and precocious puberty [8]. The possibility of
adrenal carcinomas, especially in young patients with adrenal mass, is not negligible; the incidence
of paediatric adrenocortical carcinomas (ACC), estimated in large Brazilian studies, was 3.4e4.2 per
million children. Ectopic ACTH secretion (EAS) cases are just little more than anecdotal in pediatric
age range [9].
Clinical presentation
Patients with CS display a peculiar clinical picture, which is usually the cause of their referral to the
physician. Even though features like purple striae, mainly located at abdominal level, thin skin with
easy bruising and proximal atrophy of upper and lower limbs are pathognomonic of cortisol excess,
they are not invariably present in CS. Conversely, other common characteristics such as weight gain,
excessive abdominal adiposity, increase irritability, fatigue, acne and hirsutism in female patients are
quite frequent also in general population [10]. Classical presentation with all these characteristics, like
the first patient described by H. Cushing, are nowadays less common thanks to the increase awareness
of endocrinologists. However, early detection can be delayed due to the variety of presentation and the
referral of patients to different subspecialists depending on their dominant symptoms (i.e. gynaeco-
logical, dermatological, cardiovascular, psychiatric, etc.); it is therefore crucial to consider the whole
clinical presentation for correct diagnosis [11]. The worldwide increase of obesity and metabolic
syndrome poses the problem of correctly identify patients potentially hiding CS without indiscrim-
inately screening all patients presenting one or more symptoms consistent with cortisol excess which
showed to be not cost-effective [12]. As general rule, patients with unusual features for their age such
as osteoporosis, hypertension, uncontrolled diabetes mellitus (DM) and patients with adrenal nodules
represent a high risk population that should be considered for hypercortisolism screening [12]. In
children weight gain might be less evident, but there is usually an arrest in growth with decrease in
height percentile and delay puberty. Conversely, precocious puberty and virilisation are often a hall-
mark of ACC [13,14].
Classical features of CS might be absent in case of EAS, especially in case of paraneoplastic syndrome
where catabolic effects of cortisol are prevalent, as a consequence of rapidity and severity of hormonal
excess. In these cases, hypokalaemia is far more frequent than in other forms of CS due to the
mineralocorticoid effect of cortisol caused by saturation of the 11b-hydroxysteroid dehydrogenase type
2 (11b-HSD2) enzyme, which inactivates cortisol into cortisone [15,16]. Interestingly, the degree of
hypercortisolism expressed as urinary free cortisol (UFC) does not correlate with the presence and
M. Barbot et al. / Best Practice & Research Clinical Endocrinology & Metabolism 34 (2020) 101380 3
severity of cortisol-related complications; for instance, age, family history and disease duration seem to
have more impact on diabetes development rather than cortisol levels [17]. However, previous papers
found a significant link between cortisol levels and cardiovascular risks factors [18e20]. It should be
noted that cortisol levels might vary importantly from one day to another, thus a single UFC or late
night salivary cortisol (LNSC) measurement might not represent the real extent of cortisol daily
exposure [21,22]. As cortisol effects are mediated through GC receptor, any change in its function might
modulate the effect of hormone binding. The polymorphisms BcI1 and N363S of GC receptor gene
(NR3C1) are known to enhance GC action, whereas the ER22/23 E K, while A3669G ones blunt GC
receptor sensitivity [23]. Other polymorphisms in genes encoding for mineralocorticoid receptor
(NR3C2), 11b-hydroxysteroid dehydrogenase type 1 (HSD11B1), and ATP-binding cassette B1 (ABCB1)
have been found to affect GC signalling in different aspects like cognitive impairment, bone density and
treatment response [24e29].
Diagnosis
The diagnosis of CS is often a challenge for clinicians, due to the variable pattern of the biochemical
parameters and the nonspecificity of clinical manifestations, particularly in states of mild hyper-
cortisolism [30,31]. Primary care physicians may suspect CS and proceed to the initial biochemical
screening tests, but further evaluations and treatment should be conducted in specialized endocri-
nology referral Centers. The diagnosis of endogenous CS should begin with a careful case history and
physical examination in order to exclude exogenous GCs intake by any route (oral, parenteral, inhaled,
or topical) [30].
First-line screening tests
The biochemical diagnosis of hypercortisolism is based on three different approaches, as recom-

mended by the Endocrine Society's guidelines [12]: 1) assessing daily cortisol excretion, by means of
24-h UFC (performed at least twice); 2) documenting the loss of normal diurnal variation in cortisol
secretion, with LNSC (at least two measurements); 3) documenting loss of feedback inhibition of
cortisol on the hypothalamic-pituitary-adrenal (HPA) axis, with 1 mg dexamethasone suppression test
(1-mg DST) or longer low-dose DST (2 mg/day for 48 h). In evaluating patients with clinical features
suggestive of CS, one can start with any of the previously mentioned approaches, based on its suit-
ability for a given patient [32,33]. In 2008, a meta-analysis reported that all screening tests have a good
diagnostic accuracy (particularly when used in combination) for the purpose of both identifying and
ruling out patients with CS [34]. However, since each tests proved to have comparable diagnostic values
[35e37], it is more reasonable to adopt a step-by-step approach rather than a combination of the 3
tests [12]; in presence of normal results but high clinical suspicion, one of the other 2 tests should be
used, bearing in mind that each test has important caveats, so that the choice of the proper test should
be individualized for each patient, to minimize false positive and false negative results [32]. Also,
mildly abnormal results may be found in a variety of conditions such as metabolic syndrome, chronic
anxiety, depression, and alcoholism, known as “pseudo-Cushing states” or functional hypercortisolism,
which may share some traits with CS, and should be excluded when interpreting the tests [30,31]. All
tests may be falsely normal in patients with cyclic Cushing's syndrome [38,39]; if the clinical suspicion
is high, testing should be repeated at intervals or when patient feels worst. Another important
consideration regards analytical methods for cortisol measurement. There are two ways to measure
cortisol: immunoassays, e.g. radioimmunoassay (RIA), enzyme-linked immunosorbent assay (ELISA),
or automated chemiluminescence (ECLIA); and liquid chromatography-tandem mass spectrometry
(LCeMS/MS). Antibody-based immunoassays can be affected by cross-reactivity with cortisone and
synthetic GCs (Table 1). Structurally-based assays like LCeMS/MS do not pose this problem and allow
for the separation of various GCs and metabolites. As a result, the upper limit of normal for the
structural assays is lower than that of the antibody-based ones. Reference ranges vary even within one
class of assay techniques, thus results must be interpreted with each assay's reference range [12,35,40].
Table 1
Main drawbacks of first-line screening tests used for the diagnosis of Cushing's syndrome.
Test Pitfalls
All tests False positives

- cross-reactivity with metabolites or synthetic GCs (immunoassays)
False negatives
- cyclic CS
UFC False positives:
- incorrect collection
- fluid intake > 5 L/day
- pregnancy
- pseudo-CS
- carbamazepine or fenofibrate (HPLC)
- drugs inhibit-cross-reactivity with metabolites or synthetic GCs
(immunoassays)ing the 11b-HSD2 enzyme (licorice, carbenoxolone)
False negatives:
- renal impairment (GFR < 60 ml/min)
- mild CS
1 mg-DST False positives:
- elevated CBG (pregnancy, estrogen therapy)
- decreased dexamethasone absorption
- drugs increasing dexamethasone metabolism by CYP3A4 enzyme
(barbiturates, phenytoin, carbamazepine, rifampicin)
- pseudo-CS
False negatives:
- impaired liver or renal function
- drugs inhibiting dexamethasone metabolism by CYP3A4 enzyme
(itraconazole, ritonavir, fluoxetine, diltiazem, cimetidine)
LNSC False positives:
- nocturnal or shift workers
- drugs inhibiting the 11b-HSD2 enzyme (licorice, carbenoxolone)
- blood contamination
- oral diseases
Not suitable for patients with insufficient saliva production (es Sjogren's syndrome)
Urinary free cortisol

UFC measures the unbound cortisol filtered by renal system, providing an integrated assessment of
total urinary cortisol excretion over a 24-h period. In contrast to plasma cortisol levels, which measure
total cortisol amount, it is not affected by factors that influence corticosteroid-binding globulin (CBG)
levels (e.g. disease states or concomitant use of different drugs) [41]. UFC values can be extremely
variable in CS patients. UFC values 4-fold greater than the upper limit of normal can be considered
diagnostic for this condition. Milder elevations can be found also in pseudo-Cushing states [41,42], and
in normal pregnant women. Although negative 24-h UFC test in three samples may exclude CS in most
cases, in rare situations (mild disease or cyclical CS) the diagnosis may be missed. As urinary cortisol
excretion depends on glomerular filtration rate and urinary volume, its measurement can be errone-
ously low in patients with renal impairment (glomerular filtration rate less than 60 ml/min), and high
when urinary volumes exceed 5 L in 24 h [43,44]. The concomitant use of medications such as car-
bamazepine and fenofibrate may interfere with some of the biochemical assays (i.e. high performance
liquid chromatography), although newer assay techniques using mass spectroscopy overcome this
problem [45,46]. A very high diagnostic accuracy of UFC, measured by LC-MS/MS method, as screening
test for CS, has been reported in recent studies (up to 97% sensitivity and 91% specificity) [35,47],
although not always confirmed by other authors [48,49].
Low-dose dexamethasone suppression tests

The 1 mg-DST consists in the oral intake of 1 mg dexamethasone between 23:00 and 24:00 h,
followed by measurement of fasting plasma cortisol between 08:00 and 09:00 h the following
morning. The test result is considered normal if cortisol levels fall below 50 nmol/L; higher values are
associated with the lack of appropriate negative feedback in CS patients [12,30]. The advantages of the
1 mg overnight DST are its ease of execution and low cost. The classical 2-d 2 mg-DST is another way to
conduct the test and is used in some Centers. The patient takes 0.5 mg dexamethasone orally every 6 h
for two days, and then plasma cortisol is measured at 09:00 h. A normal response consists of a decrease
of cortisol to less than 50 nmol/L on the morning after the last dose of dexamethasone [12,30]. This cut-
off value (50 nmol/L) is very close to the functional detection limit of some assays, so inherent assay
variability may account for slightly ‘‘abnormal’’ results in some cases [50]. For any DST, interfering
conditions causing an apparent lack of suppression include: decreased dexamethasone absorption,
drugs enhancing hepatic dexamethasone metabolism, increased concentration of CBG and pseudo-
Cushing states [12,30]. Drugs such as barbiturates, phenytoin, carbamazepine, rifampicin and
alcohol induce hepatic enzymatic clearance of dexamethasone, mediated through CYP3A4, thereby
reducing the plasma dexamethasone concentrations [51]. Conversely, dexamethasone clearance may
be reduced in patients with liver and/or renal failure. Some experts have advocated simultaneous
measurement of both cortisol and dexamethasone for these tests to ensure adequate plasma dexa-
methasone concentrations [52], but it is not performed routinely in clinical practice worldwide. False-
positive rates for the overnight DST are seen in women taking oral contraceptives and during preg-
nancy, because of increased CBG levels.
Late-night salivary cortisol

Loss of the physiological circadian rhythm of cortisol secretion is a consistent biochemical abnor-
mality in CS patients, who exhibit higher cortisol values at night [53,54]. This is the basis for mea-
surement of midnight serum cortisol or LNSC for the diagnosis of CS [12]. Biologically active free
cortisol in the blood is in equilibrium with cortisol in the saliva, and the concentration of salivary
cortisol is not affected by the rate of saliva production [55]. Saliva collection is non-invasive, easy to
perform, and also suitable for outpatients, since cortisol is stable at room temperature or refrigerator
temperature for several weeks [56,57]. To avoid any contamination, samples have to be collected away
from meals, smoking or brushing teeth. Licorice and chewing tobacco contain glycyrrhizic acid that
inhibits the 11b-hydroxysteroid dehydrogenase type 2 (11b-HSD2) enzyme of the salivary glands,
which converts cortisol to inactive cortisone, and may cause a falsely elevated LNSC [58]. Direct
contamination of the salivette by steroid-containing lotion or oral gels may also determine false-
positive results. LNSC might not be suitable for diagnosis in some individuals (i.e. shift workers in
whom circadian cortisol rhythm is blunted, people with a quantity of saliva insufficient for analysis,
those with oral diseases) [12]. Instead, it is a very useful tool to establish the diagnosis of cyclic CS,
when cortisol production fluctuates rhythmically, because it is simple and easy to repeat over time [59].
Various methods have been used to measure cortisol in the saliva, yielding differences in sensitivity
and specificity [36,56,57,60e64]. Similar to the measurements of UFC and serum cortisol, chromato-
graphic methods using mass spectrometry may give better diagnostic yield in LNSC.
Subclinical Cushing's syndrome
Subclinical CS is a condition of subtle increase of cortisol secretion without the typical signs of overt
hormonal excess, usually recognized during diagnostic work-up of incidentally discovered adrenal
mass; even though hypercortisolism is most of the time very mild, this condition can lead to metabolic
and vascular diseases, and fragility fractures [65]. The recommended screening test in this setting is the
overnight 1 mg-DST [66]. Whether subclinical CS can be easily ruled out in case of post-test cortisol
levels 50 nmol/L, its confirmation is more complex and often requires re-testing or additional hor-
monal evaluations including ACTH, UFC and LNSC, especially for post-dexamethasone results between
51 and 138 nmol/L [66]. However, even this strategy can be misleading, as the use of several tests may
be associated with an increased likelihood of at least one being a false-positive result. A recent study
showed that a panel of 14 adrenal steroids measured in plasma by LC-MS/MS method is able to identify
subclinical CS as effectively as 1 mg-DST, with superior performance compared to other routine tests
[67]. Finally, patients with subclinical CS should be screened and followed for cortisol-related com-
plications even though the progression from subclinical to overt CS is possible, but very unlikely as its
occurrence was reported in less than 1% of cases [68].
Second line tests
Once confirmed the diagnosis of CS, it comes to recognize the source hormonal excess. The
mainstay of differential diagnosis is the measurement of morning ACTH that should precede any
radiological studies; values above 20 pg/ml identify patients with ACTH-dependent CS, whereas
values < 10 pg/L are usually found in adrenal-dependent CS. Exceptions are possible, and probably
more frequent than expected, as around 30% of adrenal CS might display normal ACTH values [69]; in
fact, there is a grey zone between 10 and 20 pg/ml, in which cases CRH stimulatory test is suggested to
differentiate the two forms, as pituitary CS usually exhibits a sensible increase in ACTH levels
compared to adrenal CS [8].
To further mess up the diagnostic workup, it is to recall that ACTH measurement might have several
pitfalls including pre-analytical issues; in fact, ACTH is rapidly degraded by plasma proteases and for
this reason should be kept in pre-chilled EDTA tubes, rapidly processed and stored to avoid falsely low
values [70]. The measurement of ACTH value in discriminating CD from EAS is of poor utility; even
though ectopic CS were found to have higher ACTH levels compared to CD, there is a significant overlap
between the two conditions, hence dynamic tests should be performed [8,69]. The rationale of these
tests relays on the maintenance of physiological stimulation with CRH and suppression with high dose
dexamethasone [8]. The most reliable test to discriminate these two conditions is the CRH test that is
performed by injecting intravenously 100 mg or a weight-based (1 mg/kg) dose of synthetic ovine or
human CRH. The sensitivity of this test ranges between 70 and 90% and its specificity can reach 100% by
rising the threshold value to the detrimental of reduced sensitivity; however, results are heterogeneous
due to different types of CRH (human vs ovine CRH), ACTH assays and criteria to define ACTH and
cortisol responses [71e74].
The high dose dexamethasone suppression test (HDDST) has been used for decades in the differ-
ential diagnosis of CS [75e90], but its utility was lately questioned as its result can be predicted by the
extent of cortisol suppression after 1 mg dexamethasone challenge [91]. However, its usefulness has
been pointed-out again by recent studies where its predictive value was only slightly inferior to that of
CRH test and might represent a valuable alternative when CRH is not available, Table 2. The concordant
responses between the two tests was reported to strengthen the clinical suspicion; in details, absent
response to CRH and reduced suppression after HDDST indicated ectopic CS whereas a positive
response to both tests pointed to CD [71,74,92]. The finding of V3R overexpression on adenomatous
ACTH-secreting cells suggested the use of desmopressin (DDAVP) test as a possible alternative to CRH,
especially when the latter was not available. After the first promising results, the performance of
DDAVP proved to be worse than CRH test in this specific context, probably due to the expression of
vasopressin receptors also in a significant proportion of patients with EAS [71,93]. Overall non-invasive
tests are reported to be less accurate than bilateral inferior sinus sampling (BIPSS) in identifying the
source of ACTH, but their major problem is the lack of consensus on how to interpret the results, as
different threshold values have been proposed over time to define the complete response to each test
[94]. When challenging tests give discordant results and peculiar features like hypokalaemia are
present, the performance of BIPSS is required to avoid misdiagnosis [8].
Pituitary MRI
Magnetic resonance imaging (MRI) of the sella turcica should be obtained for all patients with
ACTH-dependent hypercortisolism [30]: MRI identification of a pituitary mass, in conjunction with
positive non-invasive endocrine tests (CRH stimulation and high-dose dexamethasone suppression
test), obviates the need for invasive diagnostic tests such as inferior petrosal sinus sampling. Pre-
operative localization of the tumor by MRI may also improve the success of neurosurgical treatment.
However, ACTH-secreting adenomas are not correctly identified by MRI in about 30e50% of cases. In
Table 2
Major papers on high dose dexamethasone suppression test performance published in the last 30 years. Suppression criteria are
expressed as percentage or absolute reduction with respect to baseline value. SE, sensitivity; SP specificity; CD, Cushing's disease;
ACS, adrenal Cushing's syndrome, EAS, ectopic Cushing's syndrome.; na, not assessed.
Paper Method Patients Suppression SE SP Accuracy

criteria
Bruno et al. 8 mg overnight 17 cases >50% 69.2% 100% 76.5%

1985 13 CD
3 ACS
1 EAS
Tyrrell et al., 1986 8 mg overnight 83 cases >50% 92% 100% 93%
76 CD
7 EAS
Grossman et al., 1988 2 mg every 6 h 28 cases >50% 76% 100% 80%
orally 21 CD
4 ACS
3 EAS
Biemond et al., 1990 7 h intravenously 121 cases >190 nmol/L 100% (CI: 95e100) 90% (CI:70e99) 98%
(1 mg/h) 90 CD (CI:93e100)
23 ACS
8 EAS
Flack et al., 1992 8 mg over 6 days 118 cases >50% for UFC 90% (CI:83e95) 79% (CI: 58e93) 75%
94 CD >80% for UFC 81% (CI:71e88) 92% (CI:73e99) (CI: 65e83)
14 ACS >90% for UFC 69% (CI:59e78) 100% (CI:59e100)
10 EAS
Dichek et al., 1994 8 mg overnight 41 cases >50% 88% (CI:73e97) 57% (CI:18e90) 76%
34 CD >68% 71% (CI:53e86) 100% (CI:59e100) (CI:60e88)
7 EAS >80% 59% (CI:41e75) 100% (CI:59e100)
Avgerinos et al., 1994 8 mg over 6 days 186 cases >90% for UFC 59% (CI:48e69) 73% (CI:50e87) 61
170 CD (CI:51e70)
1 ACS
15 EAS
Rossi et al., 1996 8 mg overnight 61 cases >50% 85% 100% 90%
41 CD
21 ACS
4 EAS
Sriussadaporn et al., 8 mg overnight 31 cases >50% 90% 100% 96.8%
1996 10 CD
20 ACS
1 EAS
Aron DC et al., 1997 8 mg overnight 73 cases >50% 81% 66.7% 77.9%
(34 cases) 58 CD
2 mg every 6 h 13 EAS
(37 cases)
Al-Saadi et al., 1998 4 8 mg in 24 h 30 cases >50% 74% 100% 83%
19 CD
11 EAS
Van den Bogaert et al., 7 h intravenously 86 cases >190 nmol/L 94.9% 62.5% na
1999 (1 mg/h) 78 CD
8 EAS
Vilar et al., 2007 8 mg overnight 52 cases >50% 78.2% 66.7% 77.8%
46 CD >80% 47.8% 100% 53.8%
6 EAS
Aytug et al., 2012 8 mg overnight 141 cases >50% 95% na na
(77 cases) 141 CD >80% 62%
or 2 mg every 6 h
(64 cases)
Ritzel et al., 2015 8 mg overnight 74 cases >50% 86% 71% na
60 CD >71% 64% 93%
14 EAS
Barbot et al., 2016 8 mg overnight 170 cases >52.7% 88% (CI 81e93) 90% (CI 68e99) na
149 CD >75% 76% 100%
21 EAS
fact, most of them measure <5 mm, are frequently located in the central or ventral portion of pi-
tuitary gland, and exhibit signal and enhancing characteristics similar to those of normal pituitary
parenchyma, often resulting in false negative MRI [69,95,96]. Several recent studies have been
performed with the purpose of better localizing the ACTH-secreting microadenomas, using specific
MRI sequences and high-field technology [97e102]. On standard MRI T1-weighted sequences, the
lesion responsible for CD usually appears as a focal area with a lesser enhancement following
contrast administration as compared to the normal pituitary gland. High spatial detail is critical and
should be achieved through the use of thin slices (2e3 mm or smaller), without an intervening gap.
The timing of post-contrast imaging is crucial, as the adenomaenormal pituitary maximal contrast
following gadolinium injection may occur in some cases within seconds and last for only few mi-
nutes. Dynamic studies, e.g. acquisition of a rapid series of scans of the pituitary in the very early
phases of contrast enhancement, may be useful to capture the early maximal contrast between tu-
mours and normal pituitary tissue and, hence, improve the sensitivity of MRI for the detection of
microadenomas. However, dynamic sequences may be also associated with a higher incidence of
false-positive results [102]. The spoiled-gradient echo three-dimensional (3D) T1 sequence (SGE) is
characterized by superior soft tissue contrast and improved spatial resolution, enabling enhanced
detection of smaller pituitary adenomas. SGE has been reported to substantially improve imaging
resolution and the diagnosis of ACTH-secreting microadenomas, with a greater sensitivity than
dynamic sequences [100,101]. Spatial resolution in MRI can be also improved by increasing the
strength of the main magnetic field. Various studies reported a significant improvement in the
detection of microadenomas with 3-T MRI compared to 1.5-T MRI in patients with proven CD [98,99].
1.5-T MRI is still the most commonly used magnetic field in the clinical practice, but 3-T MRI is
increasingly available worldwide and might be of particular clinical utility in patients with negative
or indeterminate imaging results. However, high-field imaging is not free of artifacts and may in-
crease the risk of false positive results, considering that incidentalomas are present in approximately
10e20% of general population. It should be underlined that, although improved, the diagnostic
performances of MRI remain inferior to the eye of an expert neurosurgeon, best assisted by endos-
copy [103]. Therefore, patients with proven CD should be addressed to an expert neurosurgeon for
transsphenoidal surgery despite inconclusive or normal MRI [103].
BIPSS
Bilateral inferior petrosal sinus sampling (BIPSS) is considered the gold standard to differentiate
pituitary from ectopic CS. Some authors use it routinely in all ACTH-dependent CS, whereas others only
in cases of discordant results at second line tests with negative MRI finding [3]. A central to peripheral
ACTH ratio >2 in the basal state or >3 after CRH stimulation is consistent with CD diagnosis [12].
Besides its high sensitivity and specificity, BIPSS is not completely foolproof. The major caveats are
represented by technical failure caused by incorrect cannulation of inferior petrosal sinuses due to
anatomical variants of the venous outflow or the execution of the procedure during a phase of
eucortisolism, which can depend on ongoing treatment with cortisol-lowering medications or in cases
of cyclic hypercortisolism. Hypercortisolemic status should be confirmed by hormonal testing right
before BIPSS to avoid misleading results [104]. False negative results due to incorrect vein cannulation
can be overcome by concomitant prolactin measurement to normalise ACTH values [105]. Incidence of
complications during BIPSS is reported low when performed in tertiary experienced Centers, but still
severe damages such as sinus thrombosis, hemorrhage and deep vein thrombosis have been reported
[106e108]. The use of DDAVP stimulation was also suggested as valuable alternative to CRH showing
comparable results; a central gradient >2 after DDAVP injection was found in 35/36 CD patients
(sensitivity of 95%) whereas in none of the 7 EAS cases (specificity of 100%) [109]. The use of more
potent stimulus with the combined administration of CRH plus DDAVP during BIPSS showed overall
comparable results, with a clear-cut response also in those patients with contradictory CRH and/or
HDDST tests [110]. Nevertheless, the capacity of this procedure to find intra-pituitary tumour locali-
zation is limited, irrespective of the type of stimulus used [111e115].
Comorbidities
Arterial hypertension and cardiovascular complications
Cardiovascular disease is commonly reported as the main cause of death in patients with CS.
Chronic damages from hypertension, in particular vascular atherosclerosis and cardiac remodelling,
together with thrombotic diathesis, are the most important contributors to increased mortality rate
[116e119].
Arterial hypertension
Present in about 80% of CS patients, hypertension is one of the pathology's most prevalent features,
and represents an independent predictor of mortality [15,116,120]. As in general population, the
prevalence of hypertension increases with age [30], but it is common (up to 50%) also in children and
adolescents with CS [121]. No gender-related differences in hypertension, nor marked correlations
with cortisol levels have been reported [122e124]. CS patients have similar elevations in systolic and
diastolic blood pressure values, and typically lose the normal nocturnal blood pressure reduction
(dipping), reflecting the impairment in circadian cortisol secretion [125]. Multiple mechanisms,
affecting plasma volume, peripheral vascular resistance and cardiac output, are involved in the path-
ogenesis of GC-induced hypertension [15,117,126]. Cortisol excess may influence arterial blood pressure
through its action on mineralocorticoid receptors (MRs) due to saturation of the 11b-HSD2 at the renal
tubule level, that gives intact cortisol access to the MRs with consequent higher sodium uptake and
potassium excretion. As a consequence, in patients with severe hypercortisolism (especially ectopic CS
or adrenal cancer), hypertension may be associated with hypokalemia. Activation of the renin-
angiotensin system (RAS) by GCs has been commonly described: there is a direct GC effect on the
hepatic synthesis of the plasma renin substrate (angiotensinogen), whose levels are elevated by GCs.
Renin may be suppressed, as expected, or often normal, which is inappropriate in view of the enhanced
mineralocorticoid activity associated with CS [117]. CS patients also show a greater sensitivity to
angiotensin II and its pressor activity at the peripheral levels. Endothelin-1 (ET-1), a potent vasocon-
strictor peptide with mitogenic and atherogenic effects on the smooth muscular cells, has been found
to be significantly elevated in CS patients [127]. Moreover, cortisol increases the serum concentration of
erythropoietin and causes polycythaemia; erythropoietin has also a direct vasoconstrictor effect and
might be another mediator of cortisol-induced hypertension [128]. GCs appear to upregulate the
sympathetic nervous system through the augmentation of the action of catecholamines and increasing
b-adrenergic receptor sensitivity [129,130]. GCs inhibit nitric oxide synthase (NOS) expression [131]
and can also impair the production of other potent vasodilators in the vascular endothelium such as
prostacyclin, prostaglandins and kallikreins [15,117]. Visceral obesity may contribute to insulin resis-
tance and sleep apnoea, which can exacerbate hypertension in CS patients [15,117]. Surgical treatment
of CS, or control of cortisol hypersecretion by pharmacological means usually result in resolution or
amelioration of hypertension, but some patients do not achieve complete cure, or require a prolonged
period of time for a complete response to therapy. In such cases, pharmacological antihypertensive
treatment should be used, to prevent blood vessel remodelling effects of hypertension. In general,
these patients require more than a single agent to reach the target blood pressure levels. In view of the
impairment of RAS in CS, some have proposed using ACE inhibitors or sartans as the first line therapy,
for their cardioprotective effects [117]. Adrenergic blockade and calcium channel antagonists may be
useful in combination therapy [126]. The diuretic furosemide is calciuretic, and therefore may worsen
hypercalciuria in CS patients, who are already at increased risk for osteoporotic fractures and neph-
rolithiasis [126]. Thiazides should be used carefully too, in order to avoid aggravating hypokalemia,
hyperuricemia, gout or diabetes [15]. Spironolactone should be used to control hypokalemia if needed,
and may improve blood pressure levels counteracting mineralocorticoid effects of GCs. Spironolactone
may also have a beneficial antiandrogenic effects in female patients, whereas in males it has been
associated to gynecomastia [15]. When disease remission is achieved, both systolic and diastolic blood
pressure tend to improve, but persistence of hypertension has been reported in 25e54% of patients in
remission from CS [17,132,133]. The duration of preoperative hypertension seems to be positively
correlated with its persistence after surgery and probably reflects the impact of irreversible remodeling
of the vasculature caused by long-term hypertension and/or a genetic predisposition.
Cardiac and vascular damage

Compared to matched controls, patients with active CS have an increased risk for myocardial
infarction and cardiac failure [116]. An increased prevalence of left ventricular hypertrophy (about 40%)
and concentric remodeling (20e25%), together with a decrease in systolic strain and impairment in
diastolic filling caused by an abnormal relaxation pattern, are consistently found in CS [134,135]. Using
cardiac MRI, subclinical systolic biventricular and left atrial systolic dysfunction, associated with
increased left ventricular mass was found in CS patients compared to controls [134]. Hypertension is
not the only factor determining cardiac hypertrophy and consequent dysfunction in CS [136]. The most
important ultrastructural abnormality in CS cardiomyopathy is myocardial fibrosis, which seems
directly related to cortisol action, exerted through an enhanced responsiveness to angiotensin II [137].
Activation of the mineralocorticoid receptor and GC receptor also contributes to its development [138].
Myocardial fibrosis could exacerbate the effects of hypokalaemia on QT interval prolongation seen in
patients with CS [139]. Altered autonomic cardiac regulation can contribute to the overall increased
cardiovascular risk in CS patients, as suggested by reduced heart rate variability [19,140]. Vascular
atherosclerosis is a common feature of CS. Angiogenic and growth factors including vascular endo-
thelial growth factor (VEGF) and insulin lead to a higher media to lumen ratio, intima-media thickness
(IMT), and wall thickness that are responsible for enhanced small artery resistance [1]. The IMT of both
carotid and aortic arteries can be increased [132,141]. A higher prevalence of well-defined vascular wall
plaques has also been reported in CS patients [132,141]. A major contribution of insulin resistance in
the development of vascular damage has been suggested, but different factors such as GC-induced
endothelial dysfunction, thrombotic diathesis, increase in homocysteine, could also play a role
[18,120,142]. CS is also associated with impaired microvascular reactivity, vascular smooth cell hy-
pertrophy and wall fibrosis of small arteries, probably due to MR-mediated inflammatory and profi-
brotic actions of GCs [143,144]. Vascular remodelling and increased vascular oxidative stress play a
major role in CS-associated cardiovascular comorbidities. The vascular damage is probably the cause of
the increased risk of stroke associated with CS [116]. Increased coronary calcifications and non-calcified
coronary plaque volume, quantified by multidetector CT coronary angiogram scan, have been found in
patients with active CS and may persists even after long-term remission [145,146]. Cardiovascular
changes and myocardial fibrosis are only partly reversible after successful treatment of GC excess; i.e.
left ventricular mass parameters improve considerably, but do not normalize completely [136]. Carotid
artery IMT decreases, but it remains above matched controls 1 and 5 years after cure, as well as the
prevalence of atherosclerotic plaques remains higher in CD patients than in controls even after long-
term remission [17,132,133].
Metabolic complications
CS shares many features with a far more prevalent disorder, the metabolic syndrome. Both syn-
dromes are characterized by abdominal obesity, glucose impairment, insulin resistance, dyslipidemia
and arterial hypertension [147]. These conditions may persist even after remission of CS, and pre-
sumably contribute to maintaining to some extent the risk of cardiovascular morbidity [17,147e149].
Visceral obesity
Weight excess is among the most common features of CS, with a prevalence of 57e100% of patients
(overweight: 33e48%; obesity: 25e100%) [17,119,132,133,145,150,151], without differences between
genders [122,124]. The obesity associated with CS is prevalently abdominal rather than a generalised
weight gain, with preferential visceral rather than subcutaneous accumulation of fat tissue determined
by chronic hypercortisolism [17,119,132,133,145]. Direct and indirect GC effects on the central nervous
system that influence eating behaviour can contribute to the obese phenotype of CS patients
[152e154]. An increased local generation of cortisol from cortisone may take place in visceral adipose
tissue because of high activity of 11b-HSD1. Waist circumference and waist-to-hip ratio, simple
markers of visceral obesity, are significantly higher in CS patients than in BMI-matched controls, and
correlate with blood pressure, glucose and insulin concentration [132,133]. Remission from hyper-
cortisolism with either surgery or pharmacological treatment can improve, but does not consistently
normalise weight excess, which can persist after short- (1-year) or long-term (5-year) remission
[17,132,133,155e159].
Glucose metabolism impairment

Impaired glucose metabolism may be an important contributor to the higher cardiovascular
morbidity and mortality in CS patients. From 20% to 45% of patients with endogenous CS have DM, and
10e30% have a defective glucose tolerance, thus the overall prevalence of glucose metabolism im-
pairments can come close to 70% [160]. No gender-related differences have been described in the
prevalence of this complication [122,124]. The problem may be underestimated because the presence
of DM is not always accurately investigated: fasting plasma glucose may be normal in most patients
with endogenous CS and DM [119], and an oral glucose tolerance tests (OGTT) is not always performed
[161]. DM can develop in all forms of CS [133], although a higher prevalence of DM has been reported in
patients with EAS (74%) than in those with other types of CS (e.g. 33% in CD and 34% in adrenal CS)
[123]. The severity of hypercortisolism seems to correlate with the presence of insulin resistance and
DM [119,162], though this was not confirmed in all studies [122,163]. Age, genetic predisposition and
lifestyle, combined with the duration and degree of hypercortisolism, strongly contribute to the
glucose tolerance impairment in CS patients [164]. A number of pathophysiological mechanisms un-
derlie GC-induced insulin resistance and DM [148,160,165,166]. Chronic hypercortisolism may have
pleiotropic effects on all major peripheral tissues governing glucose homeostasis, with both genomic
and nongenomic mechanisms [160]. There may also be indirect effects of GCs on peripheral insulin
sensitivity and glucose homeostasis through changes in protein and lipid metabolism. Cortisol exac-
erbates gluconeogenesis by upregulating key gluconeogenic enzymes, and induces selective insulin
resistance that impedes the inhibitory effect of insulin on hepatic glucose output [160,166]. CS in-
creases the rate of proteolysis and of muscle mass loss with consequent decreased muscle insulin
responsiveness and impaired glucose uptake [167,168]. Abdominal obesity associated with CS can
contribute to the onset of peripheral insulin resistance and DM by promoting altered insulin signalling
in adipocytes, increased lipolysis, aberrant adipokine secretion, and low-grade inflammation [160].
Chronically high circulating GC levels have a negative effect on b-cell function and adaptation to insulin
resistance: in patients with CS, glucose intolerance is associated with inadequate compensation of
insulin secretion by b-cells [165,169]. Incretin secretion seems to be unaffected by GC administration in
humans, but the insulinotropic effects of these hormones on b-cells are reduced in response to GCs
[165,170]. Bone has also been found to be involved in glucose homeostasis: prolonged GC exposure
causes a reduction in circulating osteocalcin, which in turn can enhance insulin resistance [171,172]. GC
signaling in the brain appears to influence peripheral metabolism as well, either by releasing signaling
peptides into the circulation or through the nervous system [173,174]. Finally, GC receptor poly-
morphisms may play a role in the development of metabolic complications of CS: the A3669G poly-
morphism has been found to play a protective role in CD, reducing the risk of DM, whereas the Bcl1
polymorphism in intron 2 of GC receptor has been linked to hyperinsulinemia, insulin resistance, and
obesity [175e177]. Controlling hypercortisolism is the first step towards improving glucose meta-
bolism in patients with endogenous CS [30,160]. The normalization of cortisol levels after surgery and/
or radiotherapy is generally followed by the resolution of patients’ glucose metabolism impairment.
However, insulin resistance and glucose abnormalities may persist even after hypercortisolism has
been corrected [17,178], and antidiabetic treatment may be required anyway. Glycemic impairment
might recover faster with surgical treatment in patients with adrenal CS [133]. Usually, pharmaco-
logical treatment of hypercortisolism is associated with an improvement in glucose metabolism, but
the choice of medical therapy may influence the outcome of GC-induced DM, due to the specific effects
of some drugs on glucose metabolism. Both steroidogenesis inhibitors and mifepristone positively
affect glucose metabolism, improving insulin sensitivity and glucose control [155e157,179]. Among
pituitary-directed drugs, cabergoline reduced the prevalence of impaired glucose tolerance or DM and
the need for antidiabetic drugs during long-term treatment [159]. By contrast, pasireotide worsen
glycaemic control in CD patients, particularly in those with pre-existing alterations of glucose meta-
bolism [158,180]. Pasireotide-induced DM is probably related to a direct inhibition of pancreatic insulin
and gastrointestinal incretin secretion [181]. Although correcting cortisol hypersecretion leads to an
improvement in glucose homeostasis, a specific antidiabetic treatment is often required in patients
with active CS and DM to achieve optimal glycemic control. Treating DM in patients with CD does not
essentially differ from treating it in ordinary circumstances [182]. In the chronic outpatient setting,
insulin sensitizers, especially metformin, are considered to be the first-line therapy, considering the
preponderant effect of hypercortisolism on insulin resistance. Nevertheless, some patients may need
insulin therapy or other oral agents, such as dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1
receptor agonists, sulfonylureas, or thiazolidinediones [182,183].
Dyslipidaemia
Cortisol regulates both lipolytic and adipogenic processes. Dyslipidaemia is reported in 12e72% of
CS patients, and is commonly characterised by raised total and LDL cholesterol and triglycerides, and
reduced HDL cholesterol concentrations [17,119,120,132,164,184]. An abnormal lipid profile may
persist even in “cured” patients after short- or long-term surgical remission, probably due to the
persistence of visceral obesity [17,132,133]. The effects of pharmacological treatment on the lipid
profile in CS are variable. Mitotane treatment increases concentrations of total, LDL and HDL
cholesterol and triglycerides [155]. Conversely, a reduction in total and LDL cholesterol concentrations
after 12 months of treatment was reported in patients treated with pasireotide achieving a full control
of cortisol secretion [158].
Thrombotic complications
CS induces prothrombotic state through increase of clotting factors, especially factors VIII (FVIII) and
von Willebrand (vWF), with consequent shortening of aPTT [185]. Other clotting factors such as FIX, FX
and FXI have been found to be elevated, enhancing the procoagulative cascade and thrombin gener-
ation that finally lead to fibrin thrombus formation [185,186]. Interestingly UFC levels do not correlate
with any clotting factors nor thrombotic events [187], suggesting a complex and multifactorial process
in the development of cortisol-related hypercoagulability. It is noteworthy that the alterations of
clotting factors are coupled to a compensatory increase of endogenous anticoagulants (antithrombin,
protein C and protein S), although apparently not protective towards venous thromboembolism (VTE)
[188e190]. Fibrinolytic system is not spared from having alterations in its activity, with a reported
increased plasminogen activator inhibitor type 1 (PAI-1) activity and antigen concentrations and
consequent reduced fibrinolysis [189,191]. These alterations in coagulative balance lead to an increase
of VTE, whose incidence can be up to 10 time higher than in general population, especially in the first 3
months after surgery [192]; in this time frame, a further boost in FVIII and abnormally large VWF
multimers that are capable of inducing spontaneous platelet aggregation were found [193]. This
mechanism can be enhanced also by the drop in cortisol levels after effective surgery, leading to a sort
of postoperative withdrawal syndrome associated to an inflammatory state, that results in an increase
in the acute-phase proteins like FVIII and fibrinogen [192,194,195]. The risk of VTE returns comparable
to that of general population approximately one year after remission, but a mild coagulative imbalance
may persist, to some extent, also in the long run [192]. Besides cortisol effects on coagulation pa-
rameters, other well-known prothrombotic conditions such as obesity, diabetes, hypertension and
dyslipidemia often present in CS patients, might further exacerbate the hypercoagulability state [118].
However, the mechanisms implicated in the thrombotic risk of CS involve other components than the
mere increase in procoagulative factors; vascular abnormalities, endothelial dysfunction but also
changes in blood composition like polycythemia contribute to the high incidence of VTE in these pa-
tients [1].
Bone damage
An impairment of bone status has been described in 64e100% of patients with CS [120]. Bone
mineral density (BMD), measured by dual-energy X-ray absorptiometry (DEXA), is reduced in CS pa-
tients: in particular, osteopenia occurs in 40e78% and osteoporosis in 22e57% [120]. Spontaneous or
low-energy fractures are described in 30e50% of patients, mainly at the vertebral level [30,120], and
can be the presenting manifestation of CS [196,197]. Some studies reported a higher prevalence of
osteoporosis in patients with adrenal or ectopic CS than in those with pituitary CS [198e200], sug-
gesting that adrenal androgen suppression or disease severity could negatively affect bone status in
hypercortisolemic patients, but this data were not confirmed in other studies [201]. Male patients have
a higher prevalence of osteoporosis and vertebral fractures than female [122e124]. In children, CS
causes severe growth failure and pubertal arrest, leading to reduced final adult height, and may also
cause a reduction in peak bone mass, presumably increasing the long-term risk of osteoporosis [202].
GCs influence bone and calcium metabolism at many levels [203]. Both direct effects of GCs on bone
turnover and indirect effects (through alteration of calcium homoeostasis and impairment of pituitary
hormone secretion) have been described. Catabolic effects on muscles might also have a role, leading to
muscle weakness and disuse, thus diminishing the muscle trophic effect on bone [203e205]. GCs
induce an imbalance between bone formation and bone reabsorption through the inhibition of oste-
oblast differentiation and function, promotion of osteoblast and osteocyte apoptosis and prolongation
of osteoclast lifespan. The decline in osteoblast number and function is reflected by decreased serum
levels of osteocalcin and alkaline phosphatase. The loss of cortical osteocytes induces bone micro-
architectural alterations, reducing bone surface turnover in response to mechanical forces [203].
Moreover, GCs decrease bone collagenous matrix synthesis and increase its degradation. GCs inhibit
calcium absorption from the gut through a mechanism independent of vitamin D, and also reduce
calcium reabsorption by the renal tubule, increasing the risk of nephrolithiasis [206]. Inhibition of GH
secretion and hypogonadism also contribute to decreased BMD [200,207]. Differential sensitivity of
bone cells to GC action has been described: patients with the N363S polymorphism in GC receptors and
higher 11b-HSD1 activity could have a higher likelihood of GC-induced bone damage [203,204]. It is
advisable to measure BMD with DEXA in all CS patients, and to consider antiresorptive therapy in those
with osteoporosis, taking into account that fractures tend to occur at higher BMD levels compared to
primary osteoporosis [203]. Patients with mild bone impairment could be treated only with calcium
and vitamin D supplements, whereas those with osteoporosis or fractures may require more aggressive
treatment, such as bone active therapy with bisphosphonates, teriparatide, and denosumab [208e210].
Additional therapeutic strategies, such as sex hormone replacement in men or women with hypo-
gonadism, are likely to have benefit. New data on the use of PTH in GC-induced osteoporosis are
encouraging and suggest a potential role for this anabolic therapy [209]. Deficits in bone mass may be
partially reversed after remission of hypercortisolism, although complete bone recovery may take
longer [201,211].
Neuropsychiatric disorders
Neuropsychiatric diseases are severe comorbidities of CS, in both the active and remission phases
[212]. GCs affect behavior, mood, neural activity, and a number of specific biochemical processes in the
central nervous system. The most common psychiatric diseases in CS are major depression (prevalence
50e81%), anxiety (66%), and bipolar disorders (30%). Adults with hypercortisolism have also impaired
cognitive function associated with reversible apparent loss of brain volume [212,213]. Cognitive deficits
are often specific to the medial temporal lobe declarative memory system. In contrast to adults,
hypercortisolemic children exhibit obsessive-compulsive behavior, and may show a deterioration in
school performance [13]. Chronic brain exposure to cortisol excess causes deep structural and func-
tional changes in various cerebral areas that are rich in GC receptors, particularly the hippocampus,
amygdala, prefrontal cortex and limbic system, all of which are fundamental regions for emotional and
cognitive functions [212e214]. Normalization of cortisol is the mainstay of treatment for depression in
CS. Disease remission, obtained by either surgery or pharmacological treatment, generally improves
depressive as well as other disabling psychological symptoms [215,216], but is not always followed by
complete recovery, suggesting irreversible adverse effects on the central nervous system [212]. Re-
sidual symptoms may endure in the first postoperative year or in some cases, even longer [213,215].
Adult patients studied 1 yr after surgical cure show improvement in mood but no changes in cognitive
function, with a concomitant increase, but not normalization, of brain volume. Longer follow-up pe-
riods are needed to determine whether cognitive, emotional, and anatomical abnormalities are fully
reversible [217,218]. The persistence or, rarely, the worsening of depression or anxiety after disease
remission might also depend on adrenal insufficiency and frequent overexposure to GC replacement
therapy [219]. Besides normalisation of cortisol secretion, psychotherapeutic strategies, such as
cognitive behavioural therapies and psychotropic drugs can be useful in treating psychiatric disorders
associated with CS [213].
Myopathy
GC-induced myopathy, characterized by proximal muscle atrophy and weakness, has been
frequently described in CS patients, with a prevalence ranging from 42% to 83% [120], higher in men
than in women [122]. Myopathy is slightly more prevalent in ectopic than in adrenal CS68. Compared to
obese subjects with the same fat mass, CS patients have reduced lean mass, due to muscle loss of the
limbs [220,221]. Creatinine kinase, plasma myoglobin and muscle fibre conduction velocity are
reduced in CS patients compared to healthy age-, sex- and BMI-matched controls, correlating at least in
part with disease duration [222]. GC excess induce type 2 muscle fibre atrophy through both anti-
anabolic and catabolic actions [220,223]. GCs impair protein synthesis in muscle by inhibiting amino
acid uptake, repressing the insulin-like growth factor 1 (IGF-1)-activated mechanistic target of rapa-
mycin pathway, and reducing myogenesis through downregulation of myogenin [223]. GCs also
stimulate proteolysis, particularly through the ubiquitin-proteosome system [223]. The treatment of
GC-associated myopathy should start with the correction of cortisol excess. However, muscle damage
can persist both short- and long-term after cure [148]. Experimental treatments with anabolic factors
such as IGF1, branched-chain amino acids, creatinine, testosterone, nandrolone and DHEA have been
proposed but need further investigation [224]. Only a few studies have demonstrated that aerobic and
resistance exercises are effective in attenuating GC-induced muscle atrophy [223].
Infections
GCs are used in clinical practice for their immunosuppressive action, thus it is not surprising that CS
patients are more prone to systemic bacterial and opportunist infections that can be life-threatening
[225]. A recent paper from the European registry on CS identified infections as one of the main cau-
ses of death in these patients, especially in the first 3 months after diagnosis [226]. Patients at higher
risk of infections are those with more severe hypercortisolism, namely EAS, and those with DM
[227,228]; in fact, hyperglycemia is associated with impaired cell- and antibody-mediated immune
response [229]. Finally, it should also be recalled that GC dependency following effective surgery for CS
has been associated with increased risk of death for infections, as well as in case of inadequate GC
substitution [230].
Practice points
GCs intake from any route of administration should be excluded through detail medical
history before prescribing any hormonal tests
In patients with unusual features for their age, CS should be ruled out using appropriate tests
(UFC and/or LNSC and/or 1 mg-DST)
Radiological exams should be performed only once the type of CS (ACTH-dependent or
ACTH-independent) has been established
After confirming CS, patients should be screened for cortisol-related complications and
received appropriate treatment while waiting for surgery
CS patients should be followed life-long due to the persistence of important comorbidities
even in “cured” patients
Research agenda
Define the role of dynamic testing in the differential diagnosis of patients with ACTH-
dependent CS and during post-surgical follow-up to predict long-term recurrence
Identify the most reliable test (early post-operative cortisol, DDAVP test, LNSC, 1 mg-DST)
and the proper interval of time to find patients at higher risk of recurrence who may need
tighter follow-up (within one month following neurosurgery, after 3-6-12 months and then
every 6 months at least for the first 5 years)
Develop more effective medical treatments to control hypercortisolism in patients not cured
by surgery or even as a valuable alternative to surgery
Investigate specific treatments for every cortisol-related complications in order to improve
patients life expectancy
Disclosures
None of the authors have anything to disclose.
Declaration of interest
All authors declare that they have no conflicts of interest that might be perceived as influencing the
impartiality of the reported research.
Funding
This study did not receive any specific grant from any funding agency in the public, commercial or
not-for-profit sector.
Patient consent
Not required.
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02524.

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Best Practice & Research Clinical Endocrinology & Metabolism 34 (2020) 101380

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Cushing's syndrome: Overview of clinical

First-line screening tests

The biochemical diagnosis of hypercortisolism is based on three different approaches, as recom-

All tests False positives

Urinary free cortisol

Low-dose dexamethasone suppression tests

Late-night salivary cortisol

Subclinical Cushing's syndrome

Second line tests

Paper Method Patients Suppression SE SP Accuracy

Bruno et al. 8 mg overnight 17 cases >50% 69.2% 100% 76.5%

Arterial hypertension and cardiovascular complications

Cardiac and vascular damage

Glucose metabolism impairment

None of the authors have anything to disclose.

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