Cushing syndrome usually results from taking corticosteroids to treat a medical disorder or from a tumor in the pituitary or adrenal gland that causes the adrenal glands to produce excessive corticosteroids.
Cushing syndrome can also result from tumors in other locations (such as the lungs).
People with Cushing syndrome usually develop excessive fat throughout the torso and have a large, round face and thin skin.
Doctors measure the level of cortisol and do other tests to detect Cushing syndrome.
Surgery or radiation therapy is often needed to remove a tumor.
(See also Overview of the Adrenal Glands Overview of the Adrenal Glands The body has two adrenal glands, one near the top of each kidney. They are endocrine glands, which secrete hormones into the bloodstream. Each adrenal gland has two parts. Medulla: The inner... read more .)
The adrenal glands may overproduce corticosteroids because of a problem in the adrenal glands or because of too much stimulation from the pituitary gland Overview of the Pituitary Gland The pituitary is a pea-sized gland that is housed within a bony structure (sella turcica) at the base of the brain. The sella turcica protects the pituitary but allows very little room for expansion... read more , which controls the adrenal glands and other endocrine glands Endocrine Glands The endocrine system consists of a group of glands and organs that regulate and control various body functions by producing and secreting hormones. Hormones are chemical substances that affect... read more . An abnormality in the pituitary gland, such as a tumor, can cause the pituitary to produce large amounts of adrenocorticotropic hormone (ACTH, also known as corticotropin), the hormone that stimulates the production of corticosteroids by the adrenal glands (a condition known as Cushing disease Cushing disease In Cushing syndrome, the level of corticosteroids is excessive, usually due to taking corticosteroid drugs or overproduction by the adrenal glands. Cushing syndrome usually results from taking... read more ). Tumors outside the pituitary gland, such as small cell lung cancer or a carcinoid tumor Carcinoid Tumors and Carcinoid Syndrome Carcinoid tumors are noncancerous (benign) or cancerous (malignant) growths that sometimes produce excessive amounts of hormone-like substances (such as serotonin), resulting in the carcinoid... read more in the lungs or elsewhere in the body, can produce ACTH as well (a condition called ectopic ACTH syndrome).
Sometimes a noncancerous tumor (adenoma) develops in the adrenal glands, which causes them to overproduce corticosteroids. Adrenal adenomas are extremely common. About 10% of all people have them by the age of 70. Only a small fraction of adenomas produce excess hormone, however. Cancerous tumors of the adrenal glands are very rare, but some of them also produce excess hormone.
Cushing syndrome can also develop in people who must take large doses of corticosteroids (such as prednisone or dexamethasone) because of a serious medical condition. Corticosteroids are often used to treat many inflammatory, allergic Overview of Allergic Reactions Allergic reactions (hypersensitivity reactions) are inappropriate responses of the immune system to a normally harmless substance. Usually, allergies make people sneeze; the eyes water and itch... read more , and autoimmune Autoimmune Disorders An autoimmune disorder is a malfunction of the body's immune system that causes the body to attack its own tissues. What triggers autoimmune disorders is not known. Symptoms vary depending... read more disorders. Common examples include asthma Asthma Asthma is a condition in which the airways narrow—usually reversibly—in response to certain stimuli. Coughing, wheezing, and shortness of breath that occur in response to specific triggers are... read more , rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more , systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic autoimmune inflammatory connective tissue disorder that can involve joints, kidneys, skin, mucous membranes, and blood vessel walls. Problems in the... read more , many skin disorders, and numerous other conditions. Those who must take large doses have the same symptoms as those whose body produces too much of the hormone. The symptoms can occasionally occur even if the corticosteroids are inhaled, as for asthma Asthma Asthma is a condition in which the airways narrow—usually reversibly—in response to certain stimuli. Coughing, wheezing, and shortness of breath that occur in response to specific triggers are... read more , or are used topically for a skin condition.
In addition to causing Cushing syndrome, taking large doses of corticosteroids also can suppress the function of the adrenal glands (adrenal insufficiency Adrenal Insufficiency In adrenal insufficiency, the adrenal glands do not produce enough adrenal hormones. Adrenal insufficiency may be caused by a disorder of the adrenal glands, a disorder of the pituitary gland... read more ). This suppression occurs because corticosteroids signal the hypothalamus and pituitary gland to stop producing the hormones that normally stimulate adrenal function. Thus, if the person abruptly stops taking corticosteroids, the body cannot restore adrenal function quickly enough, and temporary adrenal insufficiency results. Also, when stress occurs, the body is not able to stimulate production of the additional corticosteroids that are needed.
Therefore, doctors never stop the use of corticosteroids abruptly if people have been taking them for more than 2 or 3 weeks. Instead, doctors gradually reduce (taper) the dose over weeks and sometimes months.
Also, the dose of corticosteroids may need to be increased in people who become ill or otherwise severely stressed while taking corticosteroids. Corticosteroid use may need to be resumed in people who become ill or otherwise severely stressed within weeks of having the corticosteroid tapered and stopped.
Cushing disease is a term given specifically to Cushing syndrome caused by overstimulation of the adrenal glands, usually because of a pituitary tumor Enlargement of the Pituitary Gland Enlargement of the pituitary gland is usually due to a tumor but may be due to bleeding into the gland or involvement by some other disease, such as tuberculosis or sarcoidosis. In some cases... read more . In this disorder, the adrenal glands are overactive because the pituitary gland is overstimulating them, and not because the adrenal glands are abnormal. Symptoms of Cushing disease are similar to those of Cushing syndrome. Cushing disease is diagnosed by blood tests, or sometimes also with tests of urine and saliva. Imaging tests such as MRI (magnetic resonance imaging) or CT (computed tomography) may be done of the pituitary gland area. Cushing disease is treated with surgery or radiation to remove the pituitary tumor. If removal of the pituitary tumor can't be done or is unsuccessful, the adrenal glands can be removed surgically, or drugs can be given to reduce ACTH production or block the production or effects of the excess cortisol on tissues.
Symptoms of Cushing Syndrome
Corticosteroids alter the amount and distribution of body fat. Excessive fat develops throughout the torso and may be particularly noticeable at the top of the back (sometimes called a buffalo hump). A person with Cushing syndrome usually has a large, round face (moon face). The arms and legs are usually slender in proportion to the thickened trunk. Muscles lose their bulk, leading to weakness. The skin becomes thin, bruises easily, and heals poorly when bruised or cut. Purple streaks that look like stretch marks (striae) may develop over the abdomen and chest. People with Cushing syndrome tend to tire easily.
Over time, high corticosteroid levels raise the blood pressure (hypertension High Blood Pressure High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more ), weaken bones (osteoporosis Osteoporosis Osteoporosis is a condition in which a decrease in the density of bones weakens the bones, making breaks (fractures) likely. Aging, estrogen deficiency, low vitamin D or calcium intake, and... read more ), and diminish resistance to infections. The risk of developing kidney stones and diabetes is increased, and mental disturbances, including depression and hallucinations, may occur. Women usually have an irregular menstrual cycle. Children with Cushing syndrome grow slowly and remain short. In some people, the adrenal glands also produce large amounts of male sex hormones (testosterone and similar hormones), leading to increased facial and body hair, and balding in women.
Diagnosis of Cushing Syndrome
Measure the level of cortisol in the urine, saliva, and/or blood
Other blood and imaging tests
When doctors suspect Cushing syndrome, they measure the level of cortisol, the main corticosteroid hormone. Normally, cortisol levels are high in the morning and lower late in the day. In people who have Cushing syndrome, cortisol levels are usually very high throughout the day. Cortisol levels may be checked by testing the urine, the saliva, or the blood.
If the cortisol levels are high, doctors may recommend a dexamethasone suppression test in which doctors give a dose of dexamethasone at night or over several days and then measure the level of cortisol in the morning. Dexamethasone normally suppresses the secretion of corticotropin by the pituitary gland and should lead to suppression of cortisol secretion by the adrenal glands. If Cushing syndrome is caused by too much pituitary stimulation (Cushing disease), the blood level of cortisol will fall to some extent, although not as much as in people who do not have Cushing syndrome. A high ACTH level further suggests overstimulation of the adrenal gland by the pituitary.
If Cushing syndrome has another cause, the level of cortisol will remain high after giving dexamethasone. If a tumor in the adrenal produces too much cortisol, the level of corticotropin from the pituitary is already suppressed, and dexamethasone does not decrease the blood level of cortisol. Sometimes, other types of tumors elsewhere in the body produce corticotropin-like substances that stimulate the adrenal to produce excess cortisol, but this stimulation is not suppressed by dexamethasone.
Imaging tests may be needed to determine the exact cause, including a CT or MRI scan of the pituitary or adrenal glands and a chest x-ray or CT scan of the lungs or the abdomen. However, these tests may occasionally fail to find the tumor.
When overproduction of ACTH is thought to be the cause, blood samples may sometimes need to be taken from the veins that drain the pituitary to see if that is the source.
Treatment of Cushing Syndrome
Diet high in protein and potassium
Drugs that decrease cortisol levels or block the effects of cortisol
Surgery or radiation therapy
Treatment depends on whether the problem is in the adrenal glands, the pituitary gland, or elsewhere.
If the problem is caused by taking corticosteroid drugs, doctors weigh the benefit of the drug against the harm of having Cushing syndrome. Some people need to continue taking the drug even though they have Cushing syndrome. If not, doctors gradually reduce (taper) the dose over weeks and sometimes months. During the tapering, the dose may need to be temporarily increased if people become ill or otherwise severely physically stressed. Even for weeks to months after corticosteroids have been stopped, people who become ill may need to resume taking the drug because their adrenal glands have not fully recovered from suppression by the corticosteroids.
The first step people can take in the treatment of Cushing syndrome is to support their general condition by following a diet that is high in protein and potassium. Sometimes, drugs that increase potassium or lower blood glucose (sugar) levels are necessary. Any increase in blood pressure needs to be treated, and such patients are also at increased risk of blood clots in their veins, so blood thinners may be used. These patients are also especially liable to infections which may be life-threatening.
Surgery or radiation therapy Radiation Therapy for Cancer Radiation is a form of intense energy generated by a radioactive substance, such as cobalt, or by specialized equipment, such as an atomic particle (linear) accelerator. Radiation preferentially... read more (including proton beam therapy, if available) may be needed to remove or destroy a pituitary tumor.
Tumors of the adrenal glands (usually adenomas) can often be removed surgically. Both adrenal glands may have to be removed if these treatments are not effective, if a tumor is present in both adrenal glands, or if no tumor is present. People who have both adrenal glands removed, and many people who have part of their adrenal glands removed, must take corticosteroids for life.
Tumors outside the pituitary and adrenal glands that secrete excess hormones are usually surgically removed.
Certain drugs, such as metyrapone or ketoconazole, can lower cortisol levels and can be used while awaiting more definitive treatment such as surgery. Mifepristone, which can block the effects of cortisol, can also be used. People with mild cases of persistent or recurrent disease may benefit from the drug pasireotide, although this will tend to cause or worsen diabetes Diabetes Mellitus (DM) Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Urination and thirst are... read more . Cabergoline may also occasionally be useful. Pasireotide and cabergoline decrease the ability of ACTH to stimulate production of cortisol by the adrenal glands. Osilodrostat and levoketoconazole are newer drugs used to lower cortisol levels; like metyrapone and ketoconazole, they block production of cortisol in the adrenal glands.