Cushing's syndrome: a practical approach to diagnosis and differential diagnoses

Pappachan, Joseph M; Hariman, Christian; Edavalath, Mahamood; Waldron, Julian; Hanna, Fahmy

doi:10.1136/jclinpath-2016-203933

Cited by 34 publications

(29 citation statements)

References 84 publications

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“…In the present case, however, suppression was observed in HDDST. In previous studies, approximately 30% patients with ECS showed serum cortisol suppression in HDDST [3,20,21]. Moreover, because 20-33% cases of ECS were reportedly misdiagnosed because of suppressed cortisol levels, the use of other modalities such as the urinary cortisol:cortisone ratio, pituitary magnetic resonance imaging (MRI), and Gallium-68somatostatin receptor positron emission tomography/computed tomography (PET/CT) was suggested to improve the diagnostic accuracy [22][23][24].…”

Section: Discussionmentioning

confidence: 99%

Ectopic Cushing’s syndrome associated with a pheochromocytoma in a dog: a case report

Lee

Chai

et al. 2020

BMC Vet Res

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Background: Ectopic Cushing's syndrome (ECS) associated with malignant tumors, such as small cell lung carcinoma, bronchial carcinoids, and pheochromocytoma, has been reported in human medicine. However, ECS related to pheochromocytoma has not been reported in dogs. Case presentation: An 11-year-old castrated, male Scottish terrier was diagnosed with a left adrenal mass. Cushing's syndrome was suspected based on clinical signs, including pot belly, polyuria, polydipsia, bilateral alopecia, recurrent pyoderma, and calcinosis cutis. Cushing's syndrome was diagnosed on the basis of consistent clinical signs and repeated adrenocorticotropic hormone (ACTH) stimulation tests. In addition, tests for fractionated plasma metanephrine/normetanephrine suggested a pheochromocytoma. Unilateral adrenalectomy was performed after medical management with trilostane and phenoxybenzamine. Histopathology confirmed a diagnosis of pheochromocytoma without cortical lesions. After surgery, fractionated metanephrine/normetanephrine and the findings of low-dose dexamethasone suppression and ACTH stimulation tests were within the normal ranges without any medication. There were no clinical signs or evidence of recurrence and metastasis on thoracic and abdominal X-rays and ultrasonography up to 8 months after surgery. Conclusions: Pheochromocytoma should be considered a differential diagnosis for dogs with Cushing's syndrome with an adrenal tumor. A good prognosis can be expected with prompt diagnosis and surgical intervention.

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Section: Discussionmentioning

confidence: 99%

Ectopic Cushing’s syndrome associated with a pheochromocytoma in a dog: a case report

Lee

Chai

et al. 2020

BMC Vet Res

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“…In our case, the delay between the onset of the first symptoms (dorsal spinal pain) and the diagnosis was 12 months, it was the appearance of other symptoms of hypercatabolism such as skin signs that made one think of CS and prompted a specialist consultation. To confirm the diagnosis of CS, international guidelines suggest two of four investigations: two UFC, two measures of night salivary cortisol, overnight dexamethasone suppression test (ODST) or low-dose dexamethasone suppression test [ 3 , 4 ]. In our context we practice 2UFC and an ODST like most centers.…”

Section: Discussionmentioning

confidence: 99%

“…The differentiation between a dependent and non-dependent ACTH CS is very easy (step 2), but the differential diagnosis between a Cushing's disease and EAS presents a real challenge. It is the same for identifying the cause of EAS [ 2 , 4 ]. Given the severity of symptoms, normal pituitary imaging and persistence of cortisol hypersecretion after high-dose dexamethasone suppression tests, EAS was very likely.…”

Section: Discussionmentioning

confidence: 99%

Cushing´s syndrome: high aggressiveness of low-grade tumors

et al. 2020

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Cushing´s syndrome is caused by prolonged exposition supraphysiological to endogenous or exogenous cortisol. Ectopic production of adrenocorticotropic hormone by lung carcinoid tumors is relatively rare. Most documented cases have been reported individually. This rare neoplasm low grade that may secrete adrenocorticotropin (ACTH) leading to rapid development of hypercortisolism which is the main mode of discovery, can be a real aggressive form. This report shows a high aggressiveness of this endocrine neoplasia, wich was marked on the general, morphological, bone and psychiatric level. The trivialization of clinical signs had caused the delay in diagnosis with irreparable bone consequences.

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“…Glucocorticoids are considered the main cause of secondary osteoporosis [25]. The present study assessed the spectrum of bone mass and TBS in CD patients compared to subjects with normal weight and a paired group.…”

Section: Discussionmentioning

confidence: 99%

Beyond the metabolic syndrome: Visceral and marrow adipose tissues impair bone quantity and quality in Cushing’s disease

et al. 2019

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The present study was designed to evaluate the relationship between bone traits [bone mineral density (BMD) and trabecular bone score (TBS)] and the accumulation of fat in adipose tissues [abdominal subcutaneous (SAT), visceral (VAT), marrow (MAT) and intrahepatic lipids (IHL)], as well as insulin resistance, in subjects with Cushing’s disease (CD). The study included control (C = 27), paired (P = 16) and Cushing’s disease (CD = 10) groups, which underwent biochemical assessment, dual X-ray absorptiometry, TBS, and magnetic resonance imaging to determine fat deposits. The CD group showed higher serum levels of glucose and insulin, as well as HOMA-IR values, but lower circulatory levels of osteocalcin, in comparison to C and P. The CD group exhibited lower L1-L4 BMD than P (P = 1.059 ± 0.141 vs CD = 0.935 ± 0.093 g/cm2, p < 0.05) (Fig 1A). The lumbar spine BMD from the C group was similar to the other groups. TBS was lower in CD than in P and C (C = 1.512±0.077 vs P = 1.405±0.150 vs CD = 1.135±0.136; p<0.05); there was also significant difference between C and P (p<0.05). MAT, VAT, and IHL were higher in CD than in C and P (p<0.05). Considering all subjects, there was a positive association between TBS with both lumbar spine BMD (R2 = 0.45; p<0.0001) and osteocalcin (R2 = 0.44; p = 0.05). TBS was negatively associated with MAT (R2 = 0.49; p = 0.01), VAT (R2 = 0.55; p<0.05), and HOMA-IR (R2 = 0.44; p<0.01). MAT was positively related with VAT (R2 = 0.44; p<0.01) and IHL (R2 = 0.41; p<0.05). In CD, insulin resistance and adipose tissue dysfunction, including high MAT, are active players in bone deterioration, as confirmed by lower lumbar spine BMD and lower TBS. Thus, our findings point to an additional component of the already well-known complex mechanisms of osteoporosis associated with hypercortisolism.

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Cushing's syndrome: a practical approach to diagnosis and differential diagnoses

Cited by 34 publications

References 84 publications

Ectopic Cushing’s syndrome associated with a pheochromocytoma in a dog: a case report

Ectopic Cushing’s syndrome associated with a pheochromocytoma in a dog: a case report

Cushing´s syndrome: high aggressiveness of low-grade tumors

Beyond the metabolic syndrome: Visceral and marrow adipose tissues impair bone quantity and quality in Cushing’s disease

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