KNUH. Cushing s syndrome. Endocrinology & Metabolism KNUH

Transcription

1 KNUH Cushing s syndrome Endocrinology & Metabolism KNUH 2006

2 Harvey William Cushing ( ) Cast of the Hand of Harvey Cushing, 1922

3 Cushing s syndrome Hypothalamus CRH? Excess of glucocorticoids Disturbance of normal feedback CRH 증가 Pituitary ACTH? ACTH 증가 Adrenal Glucocorticoid 생산증가 Cortisol Androgen 체외로부터 Glucocorticoid 도입증가

4 Causes of Cushing s syndrome

5 Introduction Epidemiology & Prognosis incompletely controlled Cushing 5-fold excess mortality Incidence: 0.7 to 2.4 per million population per year Causes of Cushing s syndrome Iatrogenic Cushing s syndrome: the most common Ectopic ACTH secretion small cell lung cancer, bronchial carcinoid tumors any endocrine tumor from many different organs a rapid onset with severe features ACTH-independent Cushing syndrome Adrenal adenoma: 60% Adrenal carcinoma: 40% Macronodular adrenal hyperplasia

6 Pathogenesis_1 Pituitary adenoma (corticotrope tumors) little is known high proliferative activity low expression of the cyclin-dependent inhibitor p27, overexpression of cyclin E,16 and a high Ki67 expression large amounts of unprocessed POMC partly reduced by high doses of dexamethasones: in 80% of cases

7 Pathogenesis_2 AIMAH (ACTH-independent macronodular adrenal hyperplasia) food-dependent Cushing s syndrome: gastric inhibitory polypeptide vasopressin, catecholamines, IL-1, leptin, LH, serotonin, etc enhanced cyclic AMP

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9 Clinical Features_1 Obesity: commonest sign, centripetal Fat depots over thoracocervical spine: buffalo hump in supraclavicular region over cheeks & temporal region: moon face Reproductive dysfunction cortisol GnRH pulsatility 감소, LH/FSH 감소 Menstrual irregularity in female Loss of libido in both sexes, acne Hirsutism in female (androgen excess)

10 Clinical Features_2 Psychiatric abnormality Agitated depression, lethargy > paranoia, overt psychosis Bone Poor linear growth & weight gain (childhood) Osteoporotic vertebral collapse lost height Avascular necrosis Muscle Myopathy (proximal muscle) Cardiovascular HTN: 75%, Increased cardiovascular mortality Thromboembolic event

11 Clinical Features_3 Skin Skin thinning, exposure of SC vascular tissue Liddle s sign: cigarette paper appearance Bruising after minimal trauma Skin thinning + loss of facial SQ fat Plethora Red-purple striae (> 1cm) Over-stimulation of melanocyte receptor by ACTH skin pigmentation (ectopic ACTH syndrome) Infection Reactivation of tuberculosis, Fungal infection (skin, nail), wound infection & poor healing

12 Clinical Features_4 Metabolic & Endocrine Glucose intolerance, DM (1/3) Hepatic lipoprotein synthesis 증가 cholesterol, TG 증가 Hypokalemic alkalosis: 10 ~ 15% (> 95% in ectopic ACTH syndrome) Suppressed pituitary-thyroid axis, pituitary-gonadal axis Eye Raised intraocular pressure Exophthalmos increased retro-orbital fat deposition Hematologic Neutrophilia, lymphopenia, eosinopenia Protein wasting thin skin, easy bruising, proximal weakness

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16 Clues More common in iatrogenic Cushing s syndrome vs. endogenous Cushing s syndrome increased intraocular pressure, benign IICP, cataract avascular necrosis, osteoporosis, pancreatitis More common in ectopic ACTH syndrome Skin pigmentation Hypokalemic alkalosis More common in adrenal tumor Virilization in female: hirsutism, et al.

17 1 nmol/l= μg/dl 50 n/mol/l=1.8 μg/dl

18 Screening Tests Clinical Suspicion! Increased cortisol production & failure to suppress Increased cortisol production 24-hour urine free cortisol > 100 μg/day 5-10 % false positive in obese person 5 % false negative in Cushing's syndrome Circadian rhythm 상실 Midnight cortisol 7 μg/dl Cushing s syndrome (CBG-binding form: 90%, E2/Pregnancy CBG 증가 ) Midnight salivary cortisol 9AM plasma cortisol: normal in Cushing s syndrome

19 Screening Tests Overnight DEXA (1 mg) suppression test 11:00 PM~MN DEXA 1 mg p.o. (x1) Serum cortisol < 5 μg/dl exclusion of Cushing s syndrome High sensitivity, low specificity Cyclic Cushing s syndrome Pseudo-Cushing s syndrome obesity, alcoholism, psychosis, depression

20 Low-dose DEXA suppression test Dexamethasone 0.5 mg 8AM 2PM 8PM 2AM 8AM 2PM 8PM 2AM 8AM Baseline Urine Collection Post-suppression Urine Collection Interpretation Failure of urinary free cortisol to fall to less than 10 μg/day or plasma cortisol to fall to < 5 μg/dl (or 50 nmol/l) definitive diagnosis of Cushing s syndrome Sampling of Serum cortisol

21 Establishing the Cause 1 st step Measurement of plasma ACTH level ACTH-dependent or ACTH-independent? Normal ACTH level: pg/ml Decrease: adrenal Cushing Low-normal or normal: Cushing s disease >> High-normal or increase Cushing s disease << Ectopic ACTH syndrome Midnight ACTH level 23 pg/ml 이상 ACTH-dependent Undetectable ACTH-independent (adrenal)

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23 부신종양의위치결정 Adrenal CT Unilateral >> Large size (> 4 or 6 cm) carcinoma? DDX: urinary 17-KS or plasma DHEA-S Others: Adrenal USG, 131 I- iodocholesterol scan

24 Differentiating pituitary and non-pituitary_1 High-dose DEXA suppression test principle: relative sensitivity of pituitary corticotrope to the effects of glucocorticoids little diagnostic usefulness CRH test 100 μg iv bolus then measurement of ACTH & cortisol 50% increment in plasma ACTH 86% sensitivity of Cushing s disease

25 High-dose DEXA suppression test

26 Differentiating pituitary and non-pituitary_2 Invasive testing 40% of Cushing s disease: no tumor on MRI scan Bilateral inferior petrosal sinus sampling (IPSS) basal central:peripheral ratio of more than 2:1 or after stimulation more than 3:1 Cushing s disease

27 종양의위치결정 :Sella Imaging Sella MRI (CT) (with gadolinium-enhancement)

28 25/F, 3 년동안의점진적인체중증가와월경불순

29 Treatment_1 Cushing s disease Transsphenoidal surgery: treatment of choice overall remission rate: 60% over 10 years Radiation therapy persistent or recurrent Cushing s disease prevention of Nelson s syndrome Bilateral adrenalectomy Nelson s syndrome Bilateral adrenalectomy hypopituitarism, enlarged pituitary adenoma, hyperpigmentation Medical therapy mitotane, ketoconazole, metyrapone, aminoglutethimide inhibiting synthesis & secretion of cortisol from adrenal gland

30 Treatment_2 Adrenal adenoma Unilateral adenomectomy Adrenal carcinoma Surgery Medical therapy: Ketoconazole, metyrapone, mitotane, aminoglutethimide Micronodular hyperplasia of adrenal gland Bilateral adrenalectomy Ectopic ACTH syndrome Removal of tumor Bilateral adrenalectomy Medical therapy

31 KNUH Adrenal Insufficiency Endocrinology & Metabolism KNUH 2006

32 정의및분류 Addison s description General languor and debility, feebleness of the heart s action, irritability of the stomach, and a peculiar change of the color of the skin 일차성부신피질기능저하증 : Adrenal-cause Relatively rare, at any age Deficiency of glucocorticoid + mineralocorticoid 이차성부신피질기능저하증 : ACTH deficiency Relatively common because of therapeutic use of steroids Deficiency of glucocorticoid & intact mineralocorticoid

33 일차성부신피질기능저하증 일차성부신피질기능저하증 (Addison s disease) 90% 이상의부신파괴 원인 Chronic granulomatous diseases: Tuberculosis, fungus (histoplasmosis, cryptococcosis, coccidioidomycosis) Idiopathic Addison s disease: probably due to autoimmunity Hashimoto s thyroiditis, type 1 DM, polyglandular autoimmune syndrome, pernicious anemia, vitiligo, myasthenia gravis Rare causes: sepsis, hemorrhage due to anticoagulants, thrombosis, arteritis, trauma, surgery of adrenal gland, AIDS related CMV, Metastatic cancer (lung, gastric, breast, multiple myeloma), lymphoma, amyloidosis, hemochromatosis, sarcoidosis Drugs (Rifampin, phenytoin, ketoconazole, megace, opiates)

34 J.F. Kennedy

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37 이차성부신피질기능저하증 Causes Panhypopituitarism Isolated ACTH, or CRH deficiency Long-term glucocorticoid treatment (Iatrogenic Cushing s syndrome) Prolonged pituitary-hypothalamic suppression Adrenal atrophy secondary to the loss of endogenous ACTH Eventually recover!!!

38 임상소견 : 만성부신피질기능저하증 점진적인진행, Stressful condition 에서악화 Deficiency of glucocorticoid 전신쇠약, 피로감, 체중감소, 식욕부진, 구역, 구토 과색소침착 : 햇볕에노출되는부위, 압력을받는부위, palmar crease, nail bed, nipple & areola, 구강점막, 질및항문주위점막 Deficiency of mineralocorticoid Upright dizziness, Hypotension, Salt craving Hypoglycemia, hyponatremia, hyperkalemia, normocytic anemia, relative lymphocytosis, moderate eosinophilia, increase in ACTH and renin

39 임상소견 : 급성부신피질기능저하증 Chronic adrenal insufficiency stress ( adrenal crisis ) Sepsis, bilateral adrenal hemorrhage 식욕부진, 구역, 구토, 탈수, 복통, fever, Lethargy, 저혈압및 shock, 의식소실, 사망 이차성부신피질기능저하증 Hyperpigmentation (-) Electrolyte imbalance (-) Deficiency of other pituitary hormone Hypoglycemia because of combined GH-deficiency

40 진단 Clinical features & Hx Rapid ACTH stimulation test Primary vs. Secondary Not pigmented in secondary Near-normal level of aldosterone secretion in secondary Dehydration, hyponatremia & hyperkalemia favor a diagnosis of primary

41 치료 만성부신피질기능저하증 Education! (Stressful condition: 부신피질호르몬양증가 ) 이차성 : 부신피질호르몬 (+ other pituitary H) 일차성 : 부신피질호르몬 + mineralocorticoid 용량결정 : 부신피질호르몬 ( 임상상 ), mineralocorticoid (Electrolyte, BP) 급성부신피질기능저하증 : Replacement of glucocorticoid + Volume High-dose cortisol IV Normal saline IV Dopamine in patient with shock