Cushing Obesity

Differential diagnoses include diabetes mellitus and metabolic syndrome because patients with these conditions share several similar characteristics with Cushing s syndrome patients (e.g., obesity, hypertension, hyperlipidemia, hyperglycemia, and insulin resistance). In women, the presentations of hirsutism, menstrual abnormalities, and insulin resistance are similar to those of polycystic ovary syndrome. Cushing s syndrome can be differentiated from these conditions by identifying the classic signs and symptoms of truncal obesity, "moon faces" with facial plethora, a "buffalo hump" and supraclavicular fat pads, red-purple skin striae, and proximal muscle weakness. 

True Cushing s syndrome also must be distinguished from other conditions that share some clinical presentations (as well as elevated plasma cortisol concentrations), such as depression, alcoholism, obesity, and chronic illness—the so-called pseudo-Cushing s states. 

The most common findings in Cushing s syndrome are central obesity and facial rounding (90% of patients). Peripheral obesity and fat accumulation occur in 50% of patients. Fat accumulation in the dorsocervical area (buffalo hump) is a nonspecific finding, but increased supraclavicular fat pads are more specific for Cushing s syndrome. Patients are often described as having moon facies and a buffalo hump. 

Weight gain can be caused by medical conditions (e.g., hypothyroidism, Cushing s syndrome, hypothalamic lesion) or genetic syndromes (e.g., Prader-Willi s syndrome), but these are unusual to rare causes of obesity. 

Q6 Brian s muscle weakness, tiredness, weight gain, redistribution of body fat (truncal obesity), limb muscle atrophy, frequent infections, changes in mood and attitude are characteristic of Cushing s disease, which is caused by hypersecretion of glucocorticoids. If his plasma and urinary cortisol is also found to be elevated above the normal value or there is found to be overproduction of ACTH, this confirms the diagnosis. Cushing s syndrome is less common, exhibits more severe symptoms and occurs when there is excessive secretion of cortisol. 

Cushing s syndrome is caused by the hypersecretion of cortisol by cells in the adrenal cortex. Hypersecretion can be due to overstimulation of cortisol-releasing mechanisms by excess ACTH, a pituitary hormone. Cushing s can result from pituitary or adrenal tumors. It is further characterized by obesity, a rounded face, muscle weakness, a tendency to bruise easily, and numerous other complications. 

Obesity is a condition that is influenced by genetic and environmental factors (such as energy intake and expenditure, fetal nutrition, culture). There are four major physiological causes of obesity endocrine disorders (growth hormone deficiency, Cushing syndrome), genetic syndromes (Prader-Willi syndrome or Alstrom syndrome), disorders of the central nervous system (tumor, trauma) or the most common cause, multifactorial or primary obesity (caused by an interaction of multiple genes). 

The most common side effects of systemic corticosteroids include behavior disturbances, insomnia, weight gain, and Cushing s syndrome (moon face, buffalo hump, hirsutism, obesity, and easy bruising). Other reactions related to the dose and duration of corticosteroid treatment include hyperglycemia, fluid retention, HTN, electrolyte imbalances. 

Interpretation In normal subjects, serum cortisol concentration is suppressed to 2 pg/dL or less after administration of 1 mg of dexamethasone. Most patients with Cushing s syndrome do not show adequate suppression, and 0800 hours cortisol concentrations are usually >10pg/dL. Serum cortisol >2pg/dL may also be seen in cases of stress, obesity, infection, acute or chronic illness, alcohol abuse, severe depression, oral contraceptive use, pregnancy, estrogen therapy, failure to take the dexamethasone, or treatment with phenytoin or phenobarbital (enhancement of dexamethasone metabolism). 

In 1912 Harvey Cushing first described a 23-year-old woman with hirsutism, obesity, and amenorrhea and called it a polyglandular syndrome with pituitary involvement Cushing s syndrome is the result of autonomous, excessive production of cortisol leading to classic symptoms characteristic of this disorder. The clinical picture includes truncal obesity, moon face, hypertension, hirsutism,... 

Obese patients tiave also presented with ciinical features that mimic true Cushing s syndrome. Truncal obesity, striae, and the excretion of elevated concentrations of 17-hydroxysteroids are features of Cushing s syndrome that occur in normal, obese subjects. Urinary free cortisol, however, is normal in the obese individual and can effectively differentiate normal subjects from those with true Cushing s syndrome. 

A patient with androgen excess can present with variable degrees of excess hair on the face, chest, abdomen, and thighs, acne, and obesity. Amenorrhea caused by androgen excess can be due to adult-onset CAH, corticotropin-dependent Cushing s syndrome, or PCOS. 

The oversecretion of hormone molecules is most often caused by a tumor. Several types of pituitary tumor cause endocrine diseases. For example, one of the most common causes of Cushing s disease is an abnormal proliferation of ACTH-producing cells. Cushing s disease is characterized by obesity, hypertension, and elevated blood glucose levels. Patients with Cushing s disease develop a characteristic appearance a puffy moon face and a buffalo hump caused by fat deposits between the shoulders. Occasionally, Cushing s disease is caused by adrenocortical tumors. 

Cushing s syndrome Obesity and abnormal fat deposition, muscle wasting, thin skin, poor wound healing and diabetes Hypersecretion of cortisol Irradiation/ surgery... 

Does the patient actually have Cushing s syndrome The possibility that a patient may have Cushing s syndrome frequently ari.ses because they are obese or hypertensive, conditions frequently encountered in the population at large. Initial investigations will in most cases exclude the diagnosis of Cushing s syndrome. 

Excessive alcohol intake can cause pseudo-Cushing s syndrome when patients may present with hypertension, truncal obesity, plethora or acne. Preliminary investigations may demonstrate hypercorti.solism which may fail to suppress with dexametha.sone. The biochemical features of Cushing s syndrome will resolve after two to three weeks abstinence. 

The "central" deposition of fat in patients, such as Corti Solemia, with Cushing s "disease" or syndrome is not readily explained because GCs actually cause lipolysis in adipose tissue. The increased appetite caused by an excess of GC and the lipogenic effects of the hyperinsulinemia that accompanies the GC-induced chronic increase in blood glucose levels have been suggested as possible causes. Why the fat is deposited centrally under these circumstances, however, is not understood. This central deposition leads to the development of a large fat pad at the center of the upper back ("buffalo hump"), to accumulation of fat in the cheeks and jowls ("moon facies") and neck area, as well as a marked increase in abdominal fat. Simultaneously, there is a loss of adipose and muscle tissue below the elbows and knees, exaggerating the appearance of "central obesity" in Cushing s "disease" or syndrome. 

The accumulation of fat is highly selective in Cushing s disease the obesity spares the extremities and involves instead the subclavicular region, where it forms what is called the buffalo hump. The facial changes are typical in patients affected with Cushing s syndrome (see Fig. 8-19). Wrinkles disappear, and the face becomes round. The lips form what has been described as a fish mouth, and the plump appearance of the face has brought clinicians to describe these patients as moon-faced. 

The panoply of symptoms described above have all been described in cases of Cushing s disease. However, the full panoply is not found in all cases. Correct diagnosis requires judicious analysis of the symptoms. Thus, among patients with Cushing s disease, obesity is the most common symptom and is present in 88% of the patients however, only 38% have the typical abnormal fat distribution (truncal obesity) described above. Hypertension is found in 74% of the cases. 

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