Cushing Disease and Insulin Insufficiency

Cushing disease and insulin insufficiency Cushing : state of glucocorticoid excess from adrenal cortex Function of cortisol : provide energy in term of stress adrenal gland adrenal cortex adrenal medulla 1glomerulosa 2- fasiculata 3- reticularis secrete mineralocorticoid secrete glucocorticoid secrete androgen secrete epinephrin and norepinephrin Hypothalamus release CRH which stimulate anterior pituitary to release POMC is a precursor polypeptide Each of these peptides is packaged in large dense-core vesicles that are released from the cells by exocytosis in response to appropriate stimulation it will give alpa MSH and ACTH Causes of cushing : 1-exogenous 2-ACTH dependent Pituitart adenoma Broncial carcinod Ectopic ACTH Small cell lung carcinoma 3-ACTH independent Adrenal adenoma Adrenal carcinoma 4-psuedocushing obesity Alchol excess Major depression Exogenous cushing : 1-oral steroids 2- inhaled steroids 3- topical steroids 4- intra articular steroid 5- IV steroid 6- IM steroid 7- rectal steroid -Endogenous cushing … pituitary adenoma is the most commen cause of it Symptoms of cushing : Striae – hirsitism – weight gain – acne – fatigue – delayed wound healing – weakness – increase blood sugar – psychosis – depression – infections – moon face – bruising – multiple fracture – menstrual irregularity – infertility – heart burns – edema – headache – visual defect Signs of cushing : HTN – central obesity – thin arms and legs – moon face – plethra – acne – frontal buffness – hirsitism – dorso cervical fat pad – supra clavicular fat pad – ecchemosis – proximal myopathy – compression fracture know by kyphosis – backache – purple striae Diagnosis : 8 a.m fasting serum cortisol + ACTH Confirmation : 1-dexamethazone suppression test 2-24 hours urinary free cortisol 3-salivary cortisol (2 out of 3 will be positive to diagnose cushing) -Cushing cause loss of diurnal variation -If you do 24 hours urinary free cortisol you should be sure that the patient not on oral contraceptive -In adrenal gland malignancy , the adrenal will be in 4 to 5 cm in size and symptoms appear sudden and rapidly -If we want to differentiate if the problem from pituitary or ectopic we use high dose dexamethasone if ACTH suppressed , the problem from pituitary . if ACTH not suppressed , the problem from ectopic ACTH Nelson syndrome : In case of cushing patient may do bilateral adrenalectomy this will decrease cortisol level in circulation and increase ACTH release by pituitary , this increasing of ACTH from pituitary cause it to enlarge and local destruction so it can affect vision and cause impairment and hyperpigmentation due the increase level of ACTH Shehan syndrome Panhypopituitarism Adrenal insufficiency: glucocorticoid deficiency Types : Primary from adrenal gland Secondary from pituitary and hypothalamus Causes of primary adrenal insufficiency: 1-TB ( most commen cause ) 2-HIV 3-adrenalectomy 4-autoimmune 5-intra adrenal Hg 6-metastesis Causes of secondary adrenal insufficiency: Pituitary apoplexy – radiation – stop steroids -Prolonged use of exogenous steroid is most common cause of secondary adrenal insufficiency -In primary adrenal insufficiency there is destruction of all adrenal cortex -In secondary adrenal insufficiency there is decrease in glucocorticoid and androgen In adrenal crisis : 1-first give fluid to the patient ( saline ) 2-hydrocortisone -Hyperpigmentation in primary adrenal insufficiency -No hyperkalemia in secondary adrenal insufficiency -‫ اﻟﺒﮭﺎق‬Vitiligo = depigmentation ( autoimmune ) -Signs and symptoms important ( see the book ) Diagnosis : 1-random cortisol 2-ACTH 3-electrolyte K Ca Bicarbonate Na alkalotic mild renal failure due to dehydration 4- CBC (anemia – esinophilia ) Stimulation test : At 0 measure cortisol and ACTH THEN give synthetic ACTH At 30 min measure cortisol At 60 min measure cortisol Treatment : cortisol Group 12 with Dr . halla mouslly