Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Cushing Syndrome

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In one line

·Way too much cortisol flooding the body, no matter where it comes from.

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Normal physiology

·A loop between your brain and adrenal glands keeps cortisol in exactly the right range every minute of the day. When that loop works, cortisol rises in the morning to wake you up, climbs when you are stressed, and falls at night so you can sleep—then the cycle starts over.

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What goes wrong

·The feedback loop that keeps cortisol in the safe zone gets broken or ignored, so cortisol floods high and stays high day and night without stopping.

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Hallmark signs

·Weight gain in the center of the body (trunk obesity) with thin arms and legs
·Round, full face (moon face) and fat pad on the back of the neck (buffalo hump)
·Purple or red stretch marks (striae) on the belly, thighs, breasts, or arms
·Thin skin that bruises easily and heals slowly
·High blood sugar or new diabetes
·High blood pressure
·Weak muscles and trouble standing up from a chair or climbing stairs
·Extra hair growth on the face, chest, or back (in women) and irregular or missing periods

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Red flags · escalate now

·Sudden severe headache or vision changes (may mean a pituitary tumor is growing and pressing on the optic nerves near the brain)
·New bone fracture from a minor injury (sign that bones have become dangerously weak)
·Severe high blood pressure that does not come down with medicine (can lead to stroke or heart attack)
·Signs of infection that get worse quickly, such as fever and confusion (high cortisol weakens the immune system so the body cannot fight germs)
·Chest pain or trouble breathing (may signal a blood clot in the lungs, which is more common when cortisol is very high and blood clots more easily)

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Workup

·24-hour urine free cortisol (24-hour UFC)
·Late-night salivary cortisol (collected at 11 PM to midnight, two nights)
·Low-dose dexamethasone suppression test (1 mg overnight, or 2 mg over 2 days)
·Plasma ACTH level (drawn in the morning, ideally between 8 AM and 9 AM)
·Pituitary MRI with gadolinium contrast
·High-dose dexamethasone suppression test (8 mg overnight, or 2 mg every 6 hours for 2 days)
·CT scan of chest, abdomen, and pelvis with contrast (if ACTH is high but pituitary MRI is normal or high-dose dexamethasone does not suppress)
·Adrenal CT or MRI (if ACTH is LOW, meaning ACTH-independent Cushing)

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Treatment

·Transsphenoidal surgery (going through the nose to remove the pituitary tumor) for Cushing disease
·Remove the ectopic tumor (lung, pancreas, thymus, or gut tumor making ACTH)
·Unilateral adrenalectomy (remove one adrenal gland) if there is an adrenal tumor making cortisol on its own
·Medical therapy to block cortisol production — ketoconazole (200 to 400 mg twice daily), metyrapone (250 mg to 1 g every 6 hours), or osilodrostat (starting 2 mg twice daily) — while waiting for surgery or if surgery fails or is not possible
·Bilateral adrenalectomy (remove both adrenal glands) if the source cannot be found or removed, if surgery fails, or if medical therapy does not work or cannot be tolerated
·Lifelong glucocorticoid and mineralocorticoid replacement after bilateral adrenalectomy — hydrocortisone 15 to 25 mg per day (split into 2 or 3 doses, with the largest dose in the morning), plus fludrocortisone 0.05 to 0.1 mg daily
·Treat complications — blood pressure medicine (ACE inhibitors like lisinopril 10 to 40 mg daily, or calcium channel blockers like amlodipine 5 to 10 mg daily) for high blood pressure; insulin or metformin (starting 500 to 1000 mg daily) for diabetes; calcium 1200 mg daily and vitamin D 800 to 1000 IU daily plus bisphosphonate (alendronate 70 mg weekly or risedronate 35 mg weekly) for weak bones

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NCLEX trap

·Cushing SYNDROME is the big umbrella—too much cortisol in the body, no matter the source (a pituitary tumor, a lung tumor making hormones it shouldn't, a broken adrenal gland, or steroid pills). Cushing DISEASE is ONE specific type: a pituitary tumor making too much ACTH (the signal hormone), which then orders the adrenal glands to pump out cortisol. Always ask: Where is the extra cortisol coming from? That question splits Cushing syndrome into types and tells you how to fix it.
·If a patient has been on steroids for weeks or months, their adrenal glands have been asleep—the pills did cortisol's job, so the glands stopped making their own. If you suddenly stop the pills, the patient has NO cortisol at all. That causes adrenal crisis: dangerous low blood pressure, shock, confusion, and the patient can die. You MUST taper (slowly lower the dose over days to weeks) so the adrenal glands wake up gently and start working again. Teach every patient: never stop steroids on your own—always talk to your doctor first.
·When you see high blood pressure PLUS muscle weakness PLUS mood problems (feeling sad, cranky, or not sleeping) PLUS weight gain in the face, neck, or upper back—think Cushing syndrome FIRST. Order a late-night salivary cortisol test or a 24-hour urine cortisol test. Cushing syndrome mimics depression and high blood pressure, but treating those alone won't fix the real problem: too much cortisol. Find the cortisol source and treat THAT.
·In Cushing syndrome, treating symptoms alone is like mopping the floor while the faucet is still running. The high blood pressure and mood problems are CAUSED by too much cortisol. Find the cortisol source FIRST (pituitary tumor, adrenal tumor, lung tumor, or steroid pills). Fix that source (surgery, stop the pills, or medicine to block cortisol). Then the blood pressure and mood often get better on their own, because the root cause is gone.
·In Cushing syndrome, HIGH ACTH means the pituitary gland (or a sneaky tumor somewhere else, like the lung) is yelling at the adrenal glands to make cortisol. LOW ACTH means the adrenal gland itself is broken and making cortisol without anyone's permission—the pituitary sees all that cortisol flooding the body and shuts off ACTH to try to stop it. Both paths cause Cushing syndrome, but they need different fixes. High ACTH → find the tumor sending the signal (pituitary or lung). Low ACTH → fix the adrenal gland (usually remove it).
·The weight gain in Cushing syndrome is NOT from overeating. It happens because cortisol (the body's main stress hormone, made by the adrenal glands on top of the kidneys) signals the body to store fat in specific spots—the face (moon face), the back of the neck (buffalo hump), and the belly—while muscles shrink and get weak. No diet or exercise can fix cortisol that's too high. You have to find the source of the cortisol and treat THAT. Once cortisol drops, the body can start to heal and weight redistributes over time.

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