复旦大学：《内科学 Internal Medicine MBBS》课程教学资源（课件讲稿）内分泌和代谢_Cushing's syndrome and primary aldosteronism

Disorders of the adrenal cortex Cushing's Syndrome and Primary Aldosteronism 凌雁 Yan Ling Department of Endocrinology and Metabolism Zhongshan Hospital Fudan University

Disorders of the Adrenal Cortex Cushing’s Syndrome and Primary Aldosteronism Department of Endocrinology and Metabolism Zhongshan Hospital Fudan University 凌 雁 Yan Ling

Cushings Syndrome

Cushing’s Syndrome

Definition of Cushings syndrome Cushings syndrome comprises the symptoms and signs associated with prolonged exposure to inappropriately elevated levels of free plasma glucocorticoids The use of the term glucocorticoid in the definition covers both endogenous(cortisol) and exogenous(e.g prednisolone, dexamethasone)excess

Definition of Cushing’s Syndrome • Cushing's syndrome comprises the symptoms and signs associated with prolonged exposure to inappropriately elevated levels of free plasma glucocorticoids. • The use of the term glucocorticoid in the definition covers both endogenous (cortisol) and exogenous (e.g., prednisolone, dexamethasone) excess

Cortex of the adrenal gland secretes cortisol Adrenal gland Cortex Medulla Kidney Zona glomerulosa Zona Fasciculata Adrenal Zona reticularis land Kidney Medulla

Cortex of the Adrenal Gland Secretes Cortisol Zona Glomerulosa Zona Fasciculata Zona Reticularis Medulla

Regulation of Cortisol Secretion: Feedback Loops Circadian Stress rhythm Hypothalamic Hypothalamus CRH Anterior Pituitary · Adrenal cortex ACTH pituitary Cortisol Adrena CRH: corticotropin-releasing Immune Liv ver Muscle Adipose system tissue hormone Function Gluco- Protein ACTH: Adrenocorticotropic suppressed neogenesis catabolism Lipolysis hormone

Regulation of Cortisol Secretion: Feedback Loops • Hypothalamic • Anterior Pituitary • Adrenal cortex CRH: corticotropin-releasing hormone ACTH: Adrenocorticotropic hormone

Causes of Cushings Syndrome ACTH-dependent Cushings disease(acTH-producing pituitary adenoma)(60-70%) Ectopic ACTH syndrome(15-20%) Ectopic CRH syndrome Macronodular adrenal hyperplasia latrogenic( treatment with ACTH 1-24) ACTH-independent Adrenal adenoma(10-20%)and carcinoma (<5%) Primary pigmented nodular adrenal hyperplasia and Carney's syndrome McCune-Albright syndrome Aberrant receptor expression(gastric inhibitory polypeptide, interleukin-1B) (ACTH-independent macronodular hyperplasia latrogenic(e.g, pharmacologic doses of prednisolone, dexamethasone)

Causes of Cushing’s Syndrome • ACTH-dependent • Cushing's disease (ACTH-producing pituitary adenoma) (60-70%) • Ectopic ACTH syndrome (15-20%) • Ectopic CRH syndrome • Macronodular adrenal hyperplasia • Iatrogenic (treatment with ACTH 1-24) • ACTH-independent • Adrenal adenoma (10-20%) and carcinoma (<5%) • Primary pigmented nodular adrenal hyperplasia and Carney's syndrome • McCune-Albright syndrome • Aberrant receptor expression (gastric inhibitory polypeptide, interleukin-1β) (ACTH-independent macronodular hyperplasia ) • Iatrogenic (e.g., pharmacologic doses of prednisolone, dexamethasone)

Effects of Glucocorticoids LH. FSH release TSH release Brain/CNS ↓ GH secretion Depression glucose t Peripheral insulin resistance f Gluconeogenesis G/ tract I Free fatty acid production Peptic ulcerations Hypertension Promotes visceral obesity ne and calcium metabolism Bone formation I Bone mass and osteoporosis protein Skin/muscle/connective tissue ↓ Linear growth rotein cataboismvcollagen breakdown

Effects of Glucocorticoids glucose lipid protein

Clinical Features of Cushing's syndrome SYMPTOMS (%Patients) SIGNS (%Patients) weight gain 91 97 Menstrual irregularity 8416 Hirsutism 8128 Generalized 5508 Psychiatric dysfunction Plethora 9430 Backache Moon facies Muscle weakness 2980 Hypertension 7444 Fractures Bruising 62103 Loss of scalp hair Red-purple striae 625 Muscle weakness OTHER FINDINGS (%Patients) Ankle edema Hypertension 74 Pigmentation 4 Diabetes 13 Impaired glucose tolerance test 37 osteoporosis Renal calculi 15

Clinical Features of Cushing’s Syndrome (%Patients) (%Patients) (%Patients)

Clinical Features of Cushing's syndrome Obesity Truncal obesity Moon face Fat deposits in supraclavicular fossa and posterior neck-buffalo hump

Clinical Features of Cushing’s Syndrome • Obesity • Truncal obesity • Moon face • Fat deposits in supraclavicular fossa and posterior neck- buffalo hump

Truncal obesity FIG. 4. Case 1. The original example(1902)of basophil (u FIGS 6 AND 7, Dr. Turney,s patient at the age of 20 and five verified) obesity years later(1913)at the height of the disorder Weight gain and obesity are the most common sign, and this is invariably centripetal in nature

Truncal Obesity Weight gain and obesity are the most common sign, and this is invariably centripetal in nature