Cushing’s disease

Cushing’s disease

Cushing disease can be defined as a condition in which the pituitary gland releases too much adrenocorticotropic hormone (ACTH).  Cushing disease is a form of Cushing syndrome. When Cushing syndrome is caused by tumor or excess growth of the pituitary gland, it is called Cushing’s disease.

The pituitary gland is an endocrine organ. It is located just below the base of the brain. The most common cause of Cushing’s disease is a type of pituitary tumor called an adenoma.

In Cushing’s disease, too much ACTH is released by the pituitary gland. ACTH stimulates the production and release of a stress hormone called cortisol. Too much ACTH stimulates the adrenal glands for making much cortisol.


Signs and symptoms:

The sign and symptoms of Cushing’s disease include:

. Obesity in upper body above the waist. The arms and legs become thin.

.Moon face (face becomes round, red & full)

. Growth retardation in children

. Skin infection or acne

. Red cheeks. This is known as “plethora “

. Purple marks on the skin of thighs, breasts and abdomen, which are 1 cm or more wide. This marks are known as striae.

. Bruising in the skin, most commonly occurring on the arms and hands.

. Back pain which occurs along with routine activities.

. Pain and tenderness in the bones

. Buffalo hump (collection of between the shoulders)

. Rib and spine fracture due to weakening of the bones.

.muscle weakness

Symptoms seen in women:

. Excess growth of hair on the face, chest, neck, abdomen and thighs

. Irregular menstrual cycle. Sometimes menstruation totally stops.

Symptoms seen in men:

. Loss of libido (decreased or no desire for having sex)

. Impotence

Vision loss:

. Large pituitary adenomas can grow upward into the brain cavity. The tumors may elevate and compress the optic chiasma.

. Bitemporal hemianopia

. Loss of visual acuity

. Inability to perceive the brightness of colors

Other signs and symptoms that may be seen:

. Some mental changes such as depression, anxiety, mood & behavioral changes

. Some patients have psychiatric disorders

. Headache, Fatigue

. High blood pressure which is often very difficult to treat

. Sometimes severe diabetes mellitus.

. Increased thirst, increased urination etc


Diagnosis of Cushing disease:

The early stages of Cushing’s disease is difficult to diagnose, because the changes in the body develop slowly.  In pregnant women, the pregnancy can worsen the sign and symptoms of Cushing’s disease. The doctor will take a complete history and conduct through physical examination. The doctor will ask the patient about symptoms and medical history.

Two types of tests are performed to diagnose Cushing’s disease.  At first tests are done for the confirmation of too much cortisol level in the body. Then other tests are done to determine the cause of the disease.

The following tests are done to confirm too much cortisol level in the body:

.  24 hours urine free cortisol (UFC). Your doctor may need two or more elevated 24-hour UFC level for confirming the diagnosis of Cushing’s disease.

. Salivary cortisol levels test (late at night and early morning). It is recommended that, not to brush the teeth prior to the collection of samples.

. Dexamethasone suppression test (in case of low dose)


The following tests are performed to determine the cause of the disease:

. ACTH level in blood

. Brain MRI (this is the best way to detect the presence of an adenoma in Cushing’s disease)

. Dexamethasone suppression test (in case of high dose)

. Corticotrophin-releasing hormone test, the hormone acts on the pituitary gland for causing the release of ACTH.

. IPSS ( inferior petrosal sinus sampling )- this test measures ACTH levels in the veins that drain the pituitary gland compared to the veins in the chest region.

Other tests:  The following additional tests can also be done for diagnostic purpose-

.Cholesterol and lipid testing

. For testing osteoporosis- bone mineral density scan

. For testing diabetes- fasting blood glucose and A1C


Treatment of Cushing’s disease:

The main treatment options include the following-

. Surgery

.Radiation therapy

. Medication

.Other treatment options

Surgery: Treatment usually involves surgery for removing the pituitary tumor, if it is possible. After surgery the pituitary gland may return to normal and slowly start to work again. During the recovery process from surgery, there is a need of cortisol replacement treatments. This replacement treatment is needed because the normal pituitary gland needs time for starting to make ACTH again. Note that, before surgery medication is necessary in a patient who is very ill.

Radiation treatment:

.If tumor is not completely removed, then radiation treatment of the pituitary gland can also be used.

Medication: .Sometimes the tumor does not respond to surgery or radiation, in this case you may need medications for stopping your body from making cortisol.

Other treatment options:

.If the above mentioned treatments are not successful, then the adrenal glands may need to be removed for stopping the high levels of cortisol from being produced by the glands. But in this scenario, removal of adrenal glands may cause the tumor of the pituitary gland to get much bigger in size. This condition is known as Nelson Syndrome.

. Sometimes you will need to replace cortisol with hydrocortisone or prednisone after surgery.


Prevention of Cushing’s disease:

For preventing Cushing’s syndrome the following measures can be helpful:

.  Getting regular check up by your doctor.Because your doctor will be able to detect the changes in your health and early detection is considered as the best defense against Cushing’s disease.

.  Eating a balanced and healthy diet. This diet can improve muscle and bone strength.

. Regularly monitoring your mental health.

. Pains and soothe aches: taking hot baths, low-impact exercises and massages.

. Exercise of brain such as crossword puzzles, solving math problems etc. these can help in cognitive recovery.

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