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Cushing Syndrome: A Clinical Case Study on SuSAN

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Added on  2021-04-19

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ACTH dependent causes include adrenal tumors that secrete glucocorticoids, diffuse ACTH secreting tumors, microretinal hyperplasia of the adrenal gland (90% being unilateral) and prolonged exposure to exogenous steroids in the management of autoimmune diseases including Systemic Lupus Erythematosus and rheumatic arthritis. ACTH dependent causes include adrenal tumors that secrete glucocorticoids, diffuse ACTH secreting tumors, microretinal hyperplasia of the adrenal gland (90% being unilateral) and prolonged exposure to exogenous steroids in

Cushing Syndrome: A Clinical Case Study on SuSAN

   Added on 2021-04-19

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CASE STUDY ON SUSAN’S CUSHING’S SYNDROMEINTRODUCTION Cushing syndrome is the clinical depiction as a result of increased levels of plasma glucocorticoids. This condition is rare but most frequently occurs in adults aged 25-50. It may beAdrenocorticotropic hormone (ACTH) reliant or in other instances autonomous. ACTH dependent causes include adrenal tumors that secrete glucocorticoids, diffuse ACTH secreting tumors, micro nodular hyperplasia of the adrenal gland (90% being unilateral) and prolonged exposure to exogenous steroids in the management of autoimmune diseases including Systemic Lupus Erythematosus and rheumatic arthritis. ACTH independent often involve receptor signaling and expression by adrenocortical cells a case seen in Beta adrenergic agonists, ADH, gonadotrophin releasing hormone (GnRH)and in ACTH producing anterior pituitary adenomas (70% of cases). It is also commonly associated with obesity and Diabetes Mellitus Type II and hypertension (National Endocrine and Metabolic Diseases Information Service (NEMDIS), July 2008).PRESENTATION Individuals with Cushing syndrome present with truncal obesity, fatty ‘buffalo’ shoulder, facial obesity hence the “moon face” appearance, poor muscle development, unproportioned arms and legs. Visible purple striae may be seen on the abdomen, arms, thighs and breasts. Women may report of infertility, irregular periods and susceptibility to fractures especially if premenopausal. In some cases, depression and anxiety disorders, hyperglycemia, fatigue and in about 85% hypertension may occur. The female-male sex based incidence ratio of Cushing syndrome due to adrenal or pituitary tumors is about 5:1.
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PATHOPHYSIOLOGY OF CUSHING SYNDROME Extended exposure of body tissues to elevated levels of cortisol(glucocorticoid) causes Cushing syndrome. ACTH-dependent causes are mainly endogenous and include Cushing’s disease (60-70%), CRH-producing hypothalamic tumors and macro nodular hyperplasia. In ACTH-independent cases foundations include ectopic cortisol production by ovarian carcinomas,small cell lung carcinomas and neuroendocrine tumors resulting in high ACTH levels. Overproduction of endogenous glucocorticoids independent of ACTH is on most occasions due to adrenocortical neoplasms(adenomas). In a homeostatic body system, the hypothalamus secretes Corticotrophin releasing hormone(CRH) to the anterior pituitary which releases Adrenocorticotrophic Hormone that act on the Zona fasciculata producing cortisol from the progenitor cholesterol. The plasma reference levels are 140-700nmol/L in the morning and 80-350nmol/L at midnight (Biochemistry Reference Ranges Goodhope,2012). Cortisol functions to stimulate gluconeogenesis in fasting state, downregulates the production of interleukin-12and Tumor Necrosis Factor Alpha by antigen presenting cells upregulating the production of IL-4, IL-10 and IL-13 by the T helper cells resulting in prevention of an overactive immune response.Furthermore, cortisol antagonizes the functioning of insulin. This results insulin resistance and decreased energy dependent translocation of glucose by the GLUT-4 transporter this in the case of Cushing syndrome the hyperactivity of cortisol results in the manifestation of diabetes mellitus type II. In calcium homeostasis in bone, cortisol results in increased resorption, there is also increased potassium efflux and reduced intestinal calcium absorption. Excess of cortisol causes osteoporosis and hyperkalemia in this case (The Journal of Clinical Endocrinology and Metabolism. 15 (2): 176–81).
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Cortisol also functions to increase the level of free amino acids through protein catabolism. It also inhibits immunoglobulins IgA and IgM, in hypercortisolism, there is evident hyperlipidemia and decreased peripheral glucose utilization as a result of liberated amino acids. There is also evident muscular atrophy, thin skin and subcutaneous tissues, scraggy thin hair and uneven fat distribution. Significant diuretic effects of cortisol occur in high cortisol levels in serum, the potassium ions are excreted and sodium retained. The salt and water retention results in the round moon face appearance seen in Cushing SyndromeThe role cortisol in the CNS cannot be overlooked. In cognition it is involved the hippocampal formation on short term memory. The control of the circadian rhythm (McDonald’s veterinary endocrinology and reproduction (5th ed) via control of the suprarchiasmatic nucleus. In Cushing syndrome sleep and mood disorders are common. Depression may also occur and psychologic stress exaggerated. In obese individuals there is elevated cortisol courtesy of cortisol regeneration from cortisone by hydroxysteroid 11-beta dehydrogenase 1.QUESTION 2 Susan’s respiratory rate was 30 breaths per minute which is higher than the normal range of 12-20 breaths per minute, she is also hypertensive with a recorded blood pressure of 160/90 mmHg (normal range of 90/60- 120/80 mmHg). Her body temperature was at 35.0°C, this is below the normal reference range of 36.5°C-37.3°C. There is also a reported increase in the pulse, the recorded value is 128bpm, the value is elevated off the normal range of 60-100bpm. There is subclinical pain with a score of 0/10. The urinary output is reduced to 5mls per hour (normal 30-80ml/per hour). The respiratory recovery after anesthesia is slow and there is a reflex apnea due to the compensatory mechanisms of the surgically induced hypoxia. The recovery from the respiratory
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