Chemistry
Adrenal related
Hypercortisolism

Author: Renu Virk, M.D. (see Authors page)

Revised: 26 January 2016, last major update January 2010

Copyright: (c) 2002-2016, PathologyOutlines.com, Inc.

PubMed Search: Hypercortisolism [title]
Cite this page: Hypercortisolism. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/chemistryadrenalhypercortisolism.html. Accessed December 8th, 2016.
Definition / General
  • Disorder of chronic exposure to high levels of cortisol in the blood, either endogenous or exogenous
Terminology
  • Also called Cushing syndrome in Adrenal Chapter
  • Cushing disease refers to a pituitary adenoma that produces excess ACTH
  • Subclinical hypercortisolism:
    • Due to incidental adrenal masses that may secrete cortisol autonomously, with no signs or symptoms of hypercortisolism (Eur J Endocrinol 2009;160:87)
    • Associated with high prevalence of hypertension, diabetes mellitus (Eur J Endocrinol 2005;153:837), obesity, dyslipidemia and osteoporosis
Epidemiology
  • Adrenal adenoma (eMedicine - Adrenal Incidentaloma) or hyperplasia
  • Adrenal carcinoma
  • ACTH secreting pituitary adenoma (Cushing disease)
  • Other tumors with ectopic ACTH production
  • Exogenous glucocorticoids
Clinical Features
  • Obesity (buffalo hump is characteristic), hypertension, glucose intolerance, moon facies, easy bruisability, striae, proximal muscle weakness, bone loss, osteonecrosis of femur head, menstrual irregularities
  • With androgen excess, females show virilization
  • Some patients may present with neuropsychological changes
Diagnosis
  • A single test cannot be used to diagnose hypercortisolism
  • Primary hypercortisolism: high serum cortisol, low plasma ACTH
  • Secondary hypercortisolism: high serum cortisol, high plasma ACTH
Laboratory
  • Increase in daily urinary cortisol excretion
  • High midnight salivary cortisol levels
  • Increase in late evening serum cortisol levels

Low dose dexamethasone suppression test:

High dose dexamethasone suppression test:
  • This test is useful in differentiating primary hypercortisolism from ACTH secreting pituitary adenoma
  • No suppression is noted in patients with ectopic ACTH secretion or adrenal adenoma

CRH after dexamethasone test:

CRH stimulation test:
  • Usually done with equivocal plasma ACTH levels
  • Indicated to differentiate Cushing disease from Cushing syndrome
  • Pituitary tumor will show increase in ACTH and cortisol levels
  • Adrenal tumor and ectopic ACTH production will not show any increase

Clinical Images

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Physical features

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Patient description

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Buffalo hump

Diagrams / Tables

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Diagnostic algorithm

Gross Images

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Adrenal adenoma