Cushing’s Disease Study Notes

Definition

Cushing’s Disease is a condition caused by excessive secretion of adrenocorticotropic hormone

Etiology and Pathophysiology

Etiology

1. Pituitary Adenoma (Most Common Cause):

o Benign tumor of the anterior pituitary leads to excessive ACTH production.

o Increased ACTH stimulates the adrenal glands to overproduce cortisol.

2. Ectopic ACTH Syndrome:

o ACTH-producing tumors outside the pituitary (e.g., small cell lung cancer, pancreatic
tumors).

3. Adrenal Causes:

o Adrenal adenoma or carcinoma leading to autonomous cortisol production.

4. Iatrogenic Cushing’s Syndrome:

o Chronic glucocorticoid therapy (e.g., prednisone) mimicking endogenous cortisol

Pathophysiology

 Increased ACTH secretion → Hyperplasia of adrenal cortex → Excessive cortisol production.

 Cortisol exerts catabolic effects, leading to:

o Protein breakdown → Muscle wasting, thin skin, osteoporosis.

o Lipogenesis and fat redistribution → Central obesity, moon face, buffalo hump.

o Glucose metabolism alterations → Hyperglycemia, insulin resistance.

o Immune suppression → Increased susceptibility to infections.

o Sodium and water retention → Hypertension and edema.

Clinical Manifestations

General Symptoms:

 Weight gain (truncal obesity, moon face, buffalo hump).

 Muscle weakness and wasting, thin extremities.

o Thin, fragile skin.

o Purple striae (abdomen, thighs, breasts).

o Easy bruising, poor wound healing.

 Metabolic Effects:

o Hyperglycemia (can lead to diabetes mellitus).

o Hypertension.

o Osteoporosis (risk of fractures).

Neurological and Psychological Symptoms:

 Mood changes, irritability, depression, anxiety.

 Insomnia, cognitive difficulties.

Reproductive Effects:

 Females: Irregular menstruation, hirsutism.

 Males: Decreased libido, erectile dysfunction.

Increased Risk of Infections:

 Delayed wound healing.

 Frequent infections due to immune suppression.

Diagnostic Studies

1. 24-hour Urine Free Cortisol Test: Elevated cortisol confirms hypercortisolism.

2. Dexamethasone Suppression Test:

o Low-dose: Failure to suppress cortisol indicates Cushing’s Syndrome.

o High-dose: Suppression suggests pituitary origin (Cushing’s Disease).

3. Late-night Salivary Cortisol Test: Elevated levels indicate loss of diurnal cortisol variation.

4. Plasma ACTH Levels:

o High or normal: Suggests Cushing’s Disease (pituitary cause).

o Low: Suggests adrenal tumor or exogenous glucocorticoid use.

5. Imaging:

o MRI of the pituitary gland (to detect adenoma).

o CT scan of the adrenal glands (to rule out adrenal tumors).

Treatment of Pituitary Adenoma (Cushing’s Disease)

1. Surgical: Transsphenoidal Pituitary Surgery (preferred treatment).

2. Radiation Therapy: Used for non-resectable tumors or recurrence.

3. Medications to Reduce Cortisol Production:

o Ketoconazole, Metyrapone, Mitotane (adrenal enzyme inhibitors).

o Pasireotide (Somatostatin Analog): Lowers ACTH secretion in pituitary tumors.

Management of Ectopic ACTH Syndrome or Adrenal Tumors:

1. Surgical removal of ACTH-secreting tumors.

2. Medical therapy for non-resectable cases.

Management of Iatrogenic Cushing’s Syndrome:

 Gradual tapering of glucocorticoid therapy to allow adrenal recovery.

Nursing Management

Assessment:

 Monitor vital signs (hypertension, tachycardia).

 Assess weight changes, fat distribution, skin integrity.

 Evaluate blood glucose levels for hyperglycemia.

 Monitor for signs of infection due to immunosuppression.

 Assess mental health status (mood swings, depression).

Nursing Interventions:

1. Patient Education:

o Importance of medication adherence and monitoring.

o Recognizing signs of adrenal insufficiency after treatment.

o Lifestyle changes (healthy diet, exercise) to prevent complications.

2. Monitor and Manage Hypertension and Hyperglycemia:

o Low-sodium diet, antihypertensive medications.

o Blood glucose monitoring and diabetic management if needed.

3. Prevent Falls and Fractures:

o Encourage weight-bearing exercises.

o Calcium and vitamin D supplements to support bone health.

o Use mild soaps and moisturizers.

o Avoid skin trauma (prevent bruising, pressure ulcers).

5. Post-Surgical Care (Transsphenoidal Surgery):

o Monitor for CSF leaks, nasal drainage.

o Avoid activities that increase intracranial pressure (coughing, straining).

o Monitor for adrenal insufficiency post-operatively.

6. Psychosocial Support:

o Address body image concerns and emotional health.

o Support groups, counseling if needed.

Conclusion

Cushing’s Disease is a serious endocrine disorder caused by excess ACTH production, leading to
cortisol overproduction. Early diagnosis and appropriate treatment—whether surgical, medical, or
supportive—are essential to managing symptoms and preventing complications. Nursing
interventions focus on patient education, metabolic management, and prevention of complications
to improve overall quality of life.