Cushing's Syndrome

Cushing's Syndrome is an excess of glucocorticoids, mineral corticoids and sex hormones. It is usually caused by a tumor of the pituitary gland or adrenal glands. It has several clinical manifestations related to increase fat accumulation and decrease proteing synthesis. Treatment normally involves surgery.

Etiology and Physionlogy
Cushings is amost always caused by a pituitary tumor causing an excess release of ACTH, the primary regulator of glucocorticoids. It affects women 2-4 times more often than men and usually presents between the ages of 20 and 40. Other possible causes of Cushing's are adrenal tumor or a tumor elsewhere, often in the lung or pancreas, that secretes ACTH. Exogenous production of ACTH by tumors occurs primarialy in men. It can also be caused by overused of medications like prednisone.

Sign's and Symptoms
Cortisol is the main culprit in Cushing's although sex hormones and mineralcorticoids are also elevated. Cortisol's main role in the body is to respond to stress. Most of the signs and symptoms unique to Cushing's are related to elevated cortisol levels although aldosterone is also increased and may cause hypretension. Labs 24 hour urine test is done to check for normal changes. These will be absent in Cushing's. ACTH levels will be normal or high if the problem is with the pituitary gland. If ACTH levels are low the problem is with the adrenal glands, medication or tumor.
 * Weight gain
 * Moon Face
 * Buffalo hump
 * Thin extremities, muscle wasting
 * Abdomen will be large, pendulous with purple striations
 * Skin will be thing, oily, easily bruised and possibly have acne.
 * Hypotensive
 * Virilism, secondary male characteristics, in womern (small brests, facial hair).
 * Decreased libido, menstrul irregularities and enlarged clitoris in women
 * Gyno and testicular atrophy in men.
 * Elevated Cortisol
 * Elevated Glucose
 * Elevated Sodium
 * Elevated ACTH
 * Reduced potassium
 * Reduced esonophils

Dexamethasone or Metropirone are used to test for Cushing's.

Treatment
Transphenoidal Hypophysectomy is the preferred way to treat a pituitary tumor and has a 90% success rate. If the problem is the adrenal's then they can be removed. Both these options will require lifelong hormone replacement therapy. Mitotane and metyrapone are both adrenal enzyme inhibitors. They will prevent the adrenal glands from making excess gluco and mineral corticoids. They are only used when the problem is an inoperable tumor elsewhere in the body.

Nursing Considerations

 * Patient education regarding need for lifetime hormone replacement
 * Massive body changes will cause distress.
 * Control electrolytes, HTN and blood sugar before surgery.
 * Watch for cerebrospinal fluid leakage post surgery.
 * High doses of IV corticosteroids are given during and for days after surgery.
 * May be hemodynamically unstable in first 48 hours post op.
 * Dose of hormones are adjusted based on fluid and electrolyte balances and patient response.
 * AM urine samples to measure for cortisol levels.