Screening for Cushing’s syndrome: Is it worthwhile?

The data suggests that Cushing is not frequent enough to support the use of routine screening in patients with morbid obesity and type 2 DM. Also only 1 % of hypertensive patients have secondary hypertension due to CS. However, screening should be considered in young patients with resistant DM and/or hypertension. Among patients with osteoporosis and vertebral fractures up to 5 % were diagnosed with subclinical hypercortisolism; most of these had adrenal adenoma. Screening for CS is important in subjects with adrenal incidentaloma, and many studies show a high prevalence (~10 %) of Cushing or subclinical CS in these patients.

Abstract

Introduction

Cushing’s syndrome (CS) is a rare disease characterized by a collection of signs and symptoms, also common in the general population without elevated cortisol secretion. During the last years more patients with CS are identified earlier and with milder disease. Many of these patients are diagnosed during screening efforts performed for certain or isolated complaints like weight gain, diabetes mellitus (DM), hypertension, osteoporosis, elevated white blood cell counts and more.

Methods

In this review article the most popular screening test performed in the studies cited was the 1-mg dexamethasone suppression test.

Conclusions

Cushing is not frequent enough to support the use of routine screening in patients with morbid obesity and type 2 DM. Also only 1 % of hypertensive patients have secondary hypertension due to CS. However, screening should be considered in young patients with resistant DM and/or hypertension. Among patients with osteoporosis and vertebral fractures up to 5 % were diagnosed with subclinical hypercortisolism; most of these had adrenal adenoma. Screening for CS is important in subjects with adrenal incidentaloma, and many studies show a high prevalence (~10 %) of Cushing or subclinical CS in these patients.

Buy this article for $39.00 at http://link.springer.com/article/10.1007%2Fs11102-015-0634-9

Menopause, Obesity, and Diabetes Top ENDO 2015 Agenda

ENDO_2015

 

Menopause, obesity, and diabetes will top the clinical agenda at the Endocrine Society’s annual meeting, ENDO 2015, with a focus on personalized and precision approaches to disease management.

Endocrine-disrupting chemicals will also take the stage at the meeting, which runs from Thursday, March 5, through Sunday, March 8, in San Diego, California. New research to be presented includes an examination of the economic costs of exposure to these chemicals and their potential teratogenic effects.

Other topics on the agenda are the effects of male obesity on a couple’s fertility, a nasal spray that could cut calorie consumption, and a renewed look at the long-term safety of menopausal hormone therapy.

“The Endocrine Society is really known for cutting-edge research,” society president Richard J Santen, MD, from the University of Virginia School of Medicine, Charlottesville, told Medscape Medical News.

“For many of us in the field, it’s the premier meeting for both science and clinical reviews and new science presentations and networking,” added steering committee chair Matthew Ringel, MD, from Wexner Medical Center, Ohio State University, Columbus. “We’re excited about trying to increase the clinical-science part of the meeting and what would be relevant to clinical, basic, and translational-research attendees.”

As always, the meeting will feature bench science, bedside medicine, and the translation from one to the other, including plenary talks on both precision and personalized approaches to menopause, new genetic discoveries in obesity that could point to novel treatment targets, the link between antihyperglycemic therapy and cardiovascular disease, and fresh insights into the mechanisms of polycystic ovary syndrome.

The meeting begins the morning of Thursday, March 5, with two presidential plenary talks: “Genomics, Pharmacogenomics, and Functional Genomics in Menopausal Women: Implications for Precision Medicine,” by oncologist James N Ingle, MD, from the Mayo Clinic, Rochester, Minnesota, and “Personalized Menopause Management: Clinical and Biomarker Data That Inform Decision Making,” by JoAnn E Manson, MD, of Brigham and Women’s Hospital, Boston, Massachusetts.

“This issue of precision medicine has been such a hot topic, but people don’t really understand it. So the fact that we’re going to feature it in the very first talk is of interest,” Dr Santen said.

While this talk will offer a glimpse of the future, individualized approaches to menopause treatment are already here and will be featured in the session immediately following the plenary, when “Treatment of Symptoms of Menopause: An Endocrine Society Clinical-Practice Guideline” will be presented.

Wide Range of Endocrine Topics Will Be Addressed

Two other clinical-practice guidelines, on management of primary adrenal insufficiency and treatment of Cushing’s syndrome, will also be revealed during the meeting, on Saturday and Sunday, respectively.

And in a special scientific session on Friday, Janet Woodcock, MD, director of the US Food and Drug Administration’s Center for Drug Evaluation and Research, will speak on “Safety and Efficacy of Diabetes Drugs: Steering Between Scylla and Charybdis.”

Meanwhile, clinically focused “Meet the Professor” sessions will address obesity and diabetes, along with a wide range of other endocrine topics, including flushing and sweating disorders, vitamin D, thyroid, gynecomastia, endocrine tumors, testosterone therapy, and genetic counseling for endocrine patients. .

The meeting’s move — from June in previous years to March — means that it is no longer back-to-back with the annual scientific sessions of the American Diabetes Association (ADA).

“We’ve moved the meeting to March, which allows us some separation from the ADA to give us an opportunity to pull in some top diabetes topics and speakers. We’ve always done that over the years, but it allows a little more focus on that area,” Dr Ringel noted.

And, he hopes, more clinicians will be able to attend both meetings going forward. “Years ago, people tried to go to both, one after the other….It’s especially hard for clinicians to be away for that length of time,” he said.

There’s another new feature for ENDO 2015 that is likely to prove popular: “Endocrine Science Social” events will take place at 6:00 pm following the afternoon symposia each day, so attendees can discuss the topics over drinks.

“The philosophy is there’s synergy between scientists and clinicians,” Dr Santen explained.

“With more than 8000 attendees expected, the meeting overall is too big for networking, so we’re going to have a social gathering after the sessions each afternoon.”

Depressed? Anxious? It Could Be An Early Symptom Of These Illnesses

In the January 2015 edition of Psychotherapy and Psychsomatics, a group of Italian researchers explored whether depression, anxiety, and other psychiatric mood disorders might be early symptoms of medical disorders, as opposed to being “just” psychological symptoms.

Their research showed that depression in particular can be a strong indicator of other forms of illness, finding it “to be the most common affective prodrome [early symptom] of medical disorders and was consistently reported in Cushing’s syndrome, hypothyroidism, hyperparathyroidism, pancreatic and lung cancer, myocardial infarction, Wilson’s disease, and AIDS.”

Read the entire article here: Depressed? Anxious? It Could Be An Early Symptom Of These Illnesses.

Exophthalmos and Cushing’s Syndrome

A woman experienced red, irritated and bulging eyes. She saw an ophthalmologist who strongly suspected Graves’ ophthalmopathy. However, the patient did not have and never had hyperthyroidism.

Indeed, she had primary hypothyroidism optimally treated with levothyroxine. Her thyroid stimulating hormone level was 1.197 uIU/mL.

An MRI of the orbits showed normal extraocular muscles without thickening, but there was mild proptosis and somewhat increased intraorbital fat content. Both thyroid-stimulating immunoglobulins as well as thyrotropin receptor antibodies were negative.

The patient presented to her primary care physician a few months later. She had experienced a 40-lb weight gain over only a few months and also had difficult-to-control blood pressure.

After failing to respond to several antihypertensive medications, her primary care physician astutely decided to evaluate for secondary causes of hypertension. A renal ultrasound was ordered to evaluate for renal artery stenosis, and the imaging identified an incidental right-sided adrenal mass. A CT confirmed a 3.4-cm right-sided adrenal mass. Her morning cortisol was slightly high at 24.7 ug/dL (4.3 – 22.4) and her adrenocorticotropic hormone was slightly low at 5 pg/mL (10-60).

At this point I saw the patient in consultation. She definitely had many of the expected clinical exam findings of Cushing’s syndrome, including increased fat deposition to her abdomen, neck, and supraclavicular areas, as well as striae. Her 24-hour urine cortisol was markedly elevated at 358 mcg/24hrs (< 45) confirming our suspicions.

She asked me, “Do you think that my eye problem could be related to this?”

“I’ve not heard of it before,” I replied, “but that doesn’t mean there can’t be a connection. Wouldn’t it be wonderful if your eyes got better after surgery?”

The patient underwent surgery to remove what fortunately turned out to be a benign adrenal adenoma.

When we saw her in follow-up 2 weeks later, her blood pressures were normal off medication and her eye symptoms had improved. I had a medical student rotating with me, so I suggested that we do a PubMed literature search.

The first article to come up was a case report titled “Exophthalmos: A Forgotten Clinical Sign of Cushing’s Syndrome.” Indeed, not only did Harvey Cushing describe this clinical finding in his original case series in 1932, but others have reported that up to 45% of patients with active Cushing’s syndrome have exophthalmos.

The cause is uncertain but is theorized to be due to increased intraorbital fat deposition. Unlike exophthalmos due to thyroid disease, the orbital muscles are relatively normal — just as they were with our patient.

Some of you may have seen exophthalmos in your Cushing’s patients; however, this was the first time I had seen it. Just because one has not heard of something, does not mean it could never happen; no one knows everything. “When in doubt, look it up” is a good habit for both attending physicians and their students.

For more information:

Giugni AS, et al. Case Rep Endocrinol. 2013; 2013: 205208.

From http://www.healio.com/endocrinology/adrenal/news/blogs/%7B779bf3e5-e1da-459e-af27-955c9b4274a5%7D/thomas-b-repas-do-facp-face-cde/exophthalmos-and-cushings-syndrome

What Causes Overweight and Obesity?

Health Conditions

Some hormone problems may cause overweight and obesity, such as underactive thyroid (hypothyroidism), Cushing’s syndrome, and polycystic ovarian syndrome (PCOS).

Underactive thyroid is a condition in which the thyroid gland doesn’t make enough thyroid hormone. Lack of thyroid hormone will slow down your metabolism and cause weight gain. You’ll also feel tired and weak.

Cushing’s syndrome is a condition in which the body’s adrenal glands make too much of the hormone cortisol. Cushing’s syndrome also can develop if a person takes high doses of certain medicines, such as prednisone, for long periods.

People who have Cushing’s syndrome gain weight, have upper-body obesity, a rounded face, fat around the neck, and thin arms and legs.

PCOS is a condition that affects about 5–10 percent of women of childbearing age. Women who have PCOS often are obese, have excess hair growth, and have reproductive problems and other health issues. These problems are caused by high levels of hormones called androgens.

Read the entire article at http://www.nhlbi.nih.gov/health/health-topics/topics/obe/causes