Pseudo-Cushing's syndrome

Pseudo-Cushing's syndrome
Specialty	Endocrinology

Pseudo-Cushing's syndrome or non-neoplastic hypercortisolism is a medical condition in which patients display the signs, symptoms, and abnormal cortisol levels seen in Cushing's syndrome. However, pseudo-Cushing's syndrome is not caused by a problem with the hypothalamic-pituitary-adrenal axis as Cushing's is: it is mainly an idiopathic condition, though a cushingoid appearance is sometimes linked to excessive alcohol consumption. ^[1] Elevated levels of total cortisol can also be due to estrogen found in oral contraceptive pills that contain a mixture of estrogen and progesterone. Estrogen can cause an increase of cortisol-binding globulin and thereby cause the total cortisol level to be elevated. ^[2]

Diagnosis

• Levels of cortisol and ACTH both elevated
• 24-hour urinary cortisol levels elevated
• Dexamethasone suppression test ^[3]
• Late night salivary cortisol (LNSC) ^[4]
• Loss of diurnal variation in cortisol levels (seen only in true Cushing's Syndrome)
• High mean corpuscular volume and gamma-glutamyl transferase may be clues to alcoholism
• Polycystic Ovarian Syndrome should be ruled out; PCOS may have similar symptoms

Differential diagnosis

• Differentiation from Cushing's is difficult, but several tools exist to aid in the diagnosis ^[5]
• Alternative causes of Cushing's should be excluded with imaging of lungs, adrenal glands, and pituitary gland; these often appear normal in Cushing's
• In the alcoholic patient with pseudo-Cushing's, admission to hospital (and avoidance of alcohol) will result in normal midnight cortisol levels within five days, excluding Cushing's ^[6]
• Another cause for Cushing's syndrome is adrenocortical carcinoma. This is a rare form of cancer with an incidence of 1-2 per million people annually. About 60% of these cancers produce hormones, with cortisol being the most frequent. Most patients present in an advanced disease state and the outcome is dismal. ^[7]

Prognosis

• Blood results and symptoms normalise rapidly on cessation of drinking or remission of depression.^{[ citation needed ]}

References

1. Parveen June Kumar; Michael L. Clark (2005). Kumar and Clark clinical medicine. Elsevier Saunders. pp. 974–975. ISBN   978-0-7020-2763-5.
2. C. W. Burke (1969). "The effect of oral contraceptives on cortisol metabolism". Journal of Clinical Pathology. 3: 11–18. doi:10.1136/jcp.s1-3.1.11. PMC   1436049 .
3. Gatta B, Chabre O, Cortet C, et al. (November 2007). "Reevaluation of the combined dexamethasone suppression-corticotropin-releasing hormone test for differentiation of mild cushing's disease from pseudo-Cushing's syndrome" . Journal of Clinical Endocrinology and Metabolism. 92 (11): 4290–3. doi: 10.1210/jc.2006-2829 . PMID   17635947.
4. Scaroni, Carla; Albiger, Nora M; Palmieri, Serena; Iacuaniello, Davide; Graziadio, Chiara; Damiani, Luca; Zilio, Marialuisa; Stigliano, Antonio; Colao, Annamaria; Pivonello, Rosario (January 2020). "Approach to patients with pseudo-Cushing's states". Endocrine Connections. 9 (1): R1 –R13. doi:10.1530/EC-19-0435. ISSN   2049-3614. PMC   6993268 . PMID   31846432.
5. Gross BA, Mindea SA, Pick AJ, Chandler JP, Batjer HH (2007). "Diagnostic approach to Cushing disease". Neurosurgical Focus. 23 (3): 1–7. doi: 10.3171/foc.2007.23.3.2 . PMID   17961030.
6. Newell-Price J, Trainer P, Besser M, Grossman A (1998). "The diagnosis and differential diagnosis of Cushing's syndrome and pseudo-Cushing's states". Endocrine Reviews. 19 (5): 647–72. doi: 10.1210/edrv.19.5.0346 . PMID   9793762.
7. Allolio B, Fassnacht M (2006). "Adrenocortical Carcinoma: Clinical Update". Journal of Clinical Endocrinology and Metabolism. 91 (6): 2027–2037. doi: 10.1210/jc.2005-2639 . PMID   16551738.