Iatrogenic Cushing's Syndrome Research Articles

Mediastinal Lipomatosis in Simple Obesity

A case of superior mediastinal widening due to unusual amounts of fat accumulations is reported in a patient with simple obesity, not associated with iatrogenic or primary Cushing's syndrome. The radiographic features included a smooth bilateral widening of the superior mediastinum, relative lucency, no definable mass in the lateral view, and no pressure effects on the trachea. Such mediastinal lipomatosis is a benign condition and may be related to general obesity. although rare, it should be considered in the differential diagnosis of mediastinal masses, particularly in obese individuals.

Cerebral embolization resulting from esophageal-atrial fistula

While nontraumatic esophageal perforation, so-called Boerhaave syndrome, is a well-established entity, it only rarely results in a fistulous communication between the esophagus and the heart, great vessels, or pericardium. We report one such unusual lesion, an esophagealleft atrial fistula. A symptom complex, based on comparisons with previous cases, is described. With this information, future cases may be recognized in time for therapeutic intervention. <h3>PATIENT SUMMARY</h3> A 51-year-old housewife was being followed up for systemic lupus erythematosus of five-years' duration that was manifested by moderate proteinuria and hypertension. She had iatrogenic Cushing syndrome, secondary to prednisone therapy. In addition, she had a 20-year history of hiatus hernia with esophageal reflux and erosive esophagitis that was repeatedly demonstrated radiologically and by esophagoscopy. On antacid therapy, the patient experienced moderate dysphagia and suffered episodes of mild hematemesis once or twice a year. In 1968, examination revealed a distal esophageal stricture, and the patient

Cerebral Embolization Resulting From Esophageal-Atrial Fistula

A rare but catastrophic complication of nontraumatic esophageal perforation is the formation of an esophageal-left atrial fistula. Although surgical correction of this condition should be possible, failure to recognize it antemortem has thus far prevented such intervention. A woman with long-standing severe esophagitis, was admitted with hematemesis and acute neurologic abnormalities that progressed to coma and death. A similar picture of chronic esophagitis terminating in uppergastrointestinal-tract bleeding accompanied by neurologic signs was seen in the three previously reported cases as well. Recognition of this symptom complex should permit future cases to be diagnosed clinically, and, it is hoped, corrected.

GLUCOCORTICOID THERAPY

1. There is a poor relationship between the circulating half-life a glucocorticoid and either its potency or its duration of action. Many actions of a glucocorticoid have unequal durations. The duration of action varies with the dose. 2. The presence of biological activity as a glucocorticoid depends on the presence of a hydroxyl group at carbon number 11. Cortisone and prednisone, which are 11-keto compounds, must be converted to 11-beta-hydroxyl compounds to be effective. This reaction may be impaired in the presence of liver disease. 3. Iatrogenic Cushing's syndrome differs from spontaneous Cushing's syndrome in several respects, possibly because in the former ACTH is suppressed but in Cushing's syndrome associated with bilateral adrenal hyperplasia ACTH levels are elevated...

Skeletal metabolism and body composition in Cushing's syndrome.

ABSTRACT The techniques of total body neutron activation analysis and whole body counting were utilized to examine the effect of hypercortisolism on skeletal mass and body composition. Eight patients with Cushing's syndrome were studied. In addition, serum concentration of 25-hydroxycholecalciferol was measured in 4 of these patients, and in an additional 17 patients who were receiving exogenous glucocorticoids. Prior to therapy, skeletal mass (total body Ca) and lean body mass (40K) were considered to be decreased in 5 out of 7 patients. The osteopenia was generally not corrected in follow-up activations subsequent to treatment of the Cushing's syndrome. The only significant increases in total body calcium occurred in 2 patients who presumably had not completed body growth. Serum levels of 25-hydroxycholecalciferol were in the normal range in the spontaneous Cushing's, as well as the iatrogenic Cushing's syndrome patients. Thus, if glucocorticoids affect vitamin D metabolism, it must be at a step beyond ...

OPHTHALMIC STEROIDS, CUSHING'S SYNDROME AND PERSISTENT SUPPRESSION OF THE PITUITARY-ADRENAL AXIS

A 10 9/12 yr. old male presented with marked weakness, rapid wt. gain, atrophic skin, striae, truncal obesity, a buffalo hump, hirsutism and Cushingoid facies; these signs and symptoms developed during a short course of 3 retrobulbar injections of depo-triamcinolone (40 mg) and topical hydrocortisone (30 mg total over 6 weeks). This treatment was prescribed in conjunction with surgery performed for a perforating eye injury complicated by retinal detachment. Intravenous ACTH administration showed normal adrenal responses as measured by serum cortisols. Low fasting serum cortisols with loss of normal diurnal rhythm were present. Oral metapirone tests gave no responses. Withdrawal of topical steroids resulted in a rapid loss of Cushingoid features over a 3 to 6 mo. period. Tests of pituitary-adrenal function did not return to normal for 2 years; symptoms of adrenal insufficiency occurred with moderate exertion. This study outlines a new cause of iatrogenic Cushing's Syndrome with sequelae which persisted for 24 mo. It is suggested that low dose ophthalmic steroids should be used with caution; retrobulbar depo-steroids may cause prolonged pituitary suppression because of proximity to this organ.

Iatrogenic Cushing's disease in a boy after misdiagnosis of salt-losing virilizing adrenal hyperplasia: Impaired metyrapone response with failure of catch-up growth

A boy misdiagnosed as having the sodium-losing form of virilizing adrenal hyperplasia was treated with large doses of glucocorticoids and mineralocorticoids from the newborn period until he was more than 4 years of age. He developed iatrogenic Cushing's syndrome and associated glaucoma and dwarfism. The greatest catch-up linear growth took place when the mineralocorticoid had been discontinued and the glucocorticoid was being reduced, but was only of brief duration. Catch-up in skeletal maturation was greatest after complete withdrawal of steroid medication. At this time there was a normal response of urinary corticosteroids to ACTH stimulation and of serum growth hormone and plasma cortisol to insulin hypoglycemia; cortisol production rate was normal. Plasma cortisol values were in the low-normal range and responses to metyrapone were inadequate, suggesting that this boy's massive exposure to adrenocortical steroids had resulted in selective damage to his pituitary ACTH feedback mechanism. Glaucoma resulted in loss of all sight in the right eye. A boy misdiagnosed as having the sodium-losing form of virilizing adrenal hyperplasia was treated with large doses of glucocorticoids and mineralocorticoids from the newborn period until he was more than 4 years of age. He developed iatrogenic Cushing's syndrome and associated glaucoma and dwarfism. The greatest catch-up linear growth took place when the mineralocorticoid had been discontinued and the glucocorticoid was being reduced, but was only of brief duration. Catch-up in skeletal maturation was greatest after complete withdrawal of steroid medication. At this time there was a normal response of urinary corticosteroids to ACTH stimulation and of serum growth hormone and plasma cortisol to insulin hypoglycemia; cortisol production rate was normal. Plasma cortisol values were in the low-normal range and responses to metyrapone were inadequate, suggesting that this boy's massive exposure to adrenocortical steroids had resulted in selective damage to his pituitary ACTH feedback mechanism. Glaucoma resulted in loss of all sight in the right eye.

SKIN COLLAGEN IN RHEUMATOID ARTHRITIS, AND THE EFFECT OF CORTICOSTEROIDS

Skin collagen has been measured in a normal population, in patients treated with corticosteroids for rheumatoid arthritis, and in patients with rheumatoid arthritis who had not received corticosteroids. Total skin collagen is greater in men than in women and it decreases with increasing age in both sexes. The skin collagen content of the patients with rheumatoid arthritis who had not been treated with corticosteroids was lower than in the normal population but this difference was of low significance. Total skin collagen content is considerably less than normal in patients treated with corticosteroids and this decrease is related to the total dose of corticosteroid. This explains the thin skin, prominent small vessels, purpura, and striæ of spontaneous and iatrogenic Cushing's syndrome.

USE OF METHOPYRAPONE (SU-4885) IN THE STUDY OF PITUITARY-ADRENAL RESPONSE IN PATIENTS UNDER CORTICOSTEROID TREATMENT.

A study has been made of the response of the pituitary-adrenal system to the administration of Su-4885 in 27 patients (7 with endocrine disease and 20 with nonendocrine disease) under treatment with corticosteroids. The dose schedules of the corticosteroids, the length of time covered by their administration, the moment when the study was carried out (during or after suspension of the corticosteroid treatment), the manner in which suspension had taken place (suddenly or gradually over a period of several days), and the appearance of a clinical picture of iatrogenic hypercortisolism were the factors taken into consideration in order to evaluate the response to Su-4885. An abnormal response was observed in every patient in whom the administration of corticosteroids was accompanied by an intense iatrogenic Cushing's syndrome. No clear conclusions were arrived at from evaluation of the remaining factors. No attempt was made to determine the pathogenesis of the response