Chemistry, toxicology & urinalysis

Organ specific



Topic Completed: 1 January 2010

Minor changes: 2 April 2020

Copyright: 2002-2021,, Inc.

PubMed Search: Hypercortisolism [title]

Renu Virk, M.D.
Page views in 2020: 961
Page views in 2021 to date: 727
Cite this page: Virk R. Hypercortisolism. website. Accessed December 3rd, 2021.
Definition / general
  • Disorder of chronic exposure to high levels of cortisol in the blood, either endogenous or exogenous
  • 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
  • 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
  • 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
  • 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

Gross images

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Adrenal adenoma

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