Exogenous Cushing’s Syndrome

Exogenous Cushing’s syndrome is a condition caused by elevated levels of cortisol that results from excessive intake of glucocorticoids. This article discusses the causes, symptoms, and nursing interventions for Exogenous Cushing’s Syndrome. It also highlights the risks associated with the condition and provides insights on its management.

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EXOGENOUS CUSHING’S SYNDROME
Student’s Name
Institutional Affiliation

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Question 1
Exogenous Cushing’s syndrome is a condition caused by elevated levels of cortisol that
results from excessive intake of glucocorticoids. Cushing’s syndrome is an endrocrinopathy as it
results from inability of an endocrine gland to function properly. Cushing syndrome can be as a
result of a primary cause and a secondary cause. The primary cause is independent of the ACTH
hormone produced by the pituitary gland. The primary causes are related to over secretion of
cortisol by the adrenal gland and include adrenal tumors (Sharma, Nieman & Feelders, 2015).
On the other hand secondary causes of Cushing’s syndrome are ACTH dependent. The pituitary
gland is also referred to as the master gland as it controls other glands within the body of which
the adrenal gland is part of them.
ACTH is secreted by the pituitary gland and has its effect on the adrenal gland where it
stimulates the release of cortisol. Increased secretion of ACTH can therefore cause abnormal
secretion of cortisol by the adrenal gland hence Cushing’s syndrome. Exogenous Cushing’s
syndrome results from excessive glucocorticoid hormone intake is ACTH independent (Morgan,
Hassan-Smith & Lavery, 2016). As the term explains, an exogenous cause of a disease is any
cause that comes from outside the body. Ms. Maureen’s case of exogenous Cushing’s syndrome
was as a result of a high dose of corticosteroid medication that was prescribed for her rheumatoid
arthritis. Prednisolone is a corticosteroid that is used to treat various medical conditions.
The incidence of Exogenous Cushing’s syndrome varies depending on the population
beliefs and perception as far as corticosteroids are concerned. Patients suffering from medical
conditions that are associated with corticosteroid intake such as rheumatoid arthritis and other
inflammatory diseases like asthma, lupus urticaria and inflammatory bowel disease tend to suffer
from the condition as compared to those who are don’t take such medications. According to

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Pivonello et al. (2016), frequency of the condition varies from one population to another
depending on cultural and ethnic backgrounds. For example, there are a number of communities
that don’t believe in taking corticosteroids due to their negative belief systems associated with
such medication. The condition is associated with excessive intake of corticosteroids and this can
be caused by exacerbation of conditions that require these types of medication. Ms. Maureen for
example sought high doses of the corticosteroid prednisolone due to exacerbation of her
rheumatic arthritis condition hence was predisposed to contracting the disease.
There are a number of risk factors associated with exogenous Cushing’s syndrome. The
main risk factor is obviously excessive intake of glucocorticoids due to a current inflammatory
medical condition. The medications of corticosteroids can either be oral doses or injectable
medicines. As stated by Pappachan et al. (2017), the risk of contracting the condition is increased
by overuse of these medications. Corticosteroids cause immune suppression. Such a disease has
a lot of impact on the patient and the family as well. The patient may undergo a lot of depression
and lose of hope in life. Because of the severity of the disease, the patient may lose their job and
this can negatively affect the family dependent on the patient as income to support and provide
for family members would no longer be there.
Question 2
There are various signs and symptoms associated with exogenous Cushing’s syndrome. A
common sign associated with the disease is weight gain and deposition of fatty tissue around the
belly and formation of a buffalo hump between the shoulders. The patient as is the case of
Sharon presents with a moon face that is the face becomes rounder. In addition to these, it can
exacerbate obesity in individuals with the condition as there is increased fat deposition in these
tissues. The pathophysiology behind these fat related signs and symptoms is the fact that

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Cushing’s syndrome is as a result of imbalances within the metabolic system of carbohydrates in
the body (Nieman, 2018).
Cortisol is a hormone that is responsible for the metabolism of carbohydrates and fat
within the body. If there is increased cortisol production or high levels of the same due to
exogenous Cushing’s syndrome, metabolism of these fats and carbohydrates is affected leading
to uneven distribution of fat and hence the presentation of central obesity and other signs.
Another major sign associated with exogenous Cushing’s syndrome is increased blood pressure
and this can cause a serious health crisis. According to Pineyro et al. (2019), hypertension is one
of the major complications of the disease and it results from increased cardiac output or
increased peripheral resistance. Since Cushing’s syndrome alters metabolism of carbohydrates,
there might be increased sugar levels within the blood. This high blood sugar levels is also
associated with diabetes and can alter blood vessels leading to increased peripheral resistance
hence a high blood pressure.
High sugar levels can also significantly affect blood volume and hence lead to increased
cardiac output hence hypertension. Another sign and symptom associated with the condition is
osteoporosis. This is a condition that affects the bones whereby there is degradation and use up
of bones at extreme levels. It occurs when there is more bone resorption as compared to bone
deposition. According to O'brien et al. (2018), the patient may present with shortened femurs and
pain within the skeletal system. There is therefore need for careful monitoring. The
pathophysiology behind this presentation is the fact that high cortisol and glucocorticoid levels
affect bone metabolism by enhancing resorption of bone.
Question 3

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Ms. Maureen was given a dose of prednisolone which she was taking daily to manage her
rheumatic arthritis condition. This drug lies under the bigger classification of drugs referred to as
corticosteroids. Corticosteroids have a series of important pharmacodynamics and
pharmacokinetics. The pharmacodynamics focusses mainly on the mechanism of action of the
drugs. Corticosteroids act by diffusing into the cells and binding into cytosolic receptors
reversibly (Rainsbury et al, 2017). The anti-inflammatory process is quite a long process that
requires a varied interaction of receptors and pathways in order to be effected. Corticosteroids
act by altering synthesis of important enzymes and proteins by interacting with the messenger
RNA and the DNA itself as a whole. An important protein referred to as lipocortin is important
in imparting corticosteroids effects.
The pharmacokinetics mainly involves the aspects of absorption, distribution, metabolism
and elimination or excretion of the drugs. Cortisol is found in blood in its free form. It binds to a
corticosteroid binding globulin. Therapeutic corticosteroids such as prednisolone are rapidly
absorbed after oral administration and reach peak plasma levels after 1 to 3 hours (Andela et al,
2015). Prednisolone is considered to be pharmacologically active as compared to its
interconvertible subtype prednisone. The bioavailability of the drug is about 80%. It is dose
dependent and the volume of distribution and clearance increases with the more of the drug dose
is taken. It is therefore well distributed in the body. Plasma clearance of the drug is dependent on
the dose intake and is longer with increased drug intake. Metabolism of corticosteroids mainly
occurs in the liver with the processes of conjugation and glucuronidation taking place. Excretion
of the drugs is via the renal route and metabolism of the drugs aims at diminishing their
physiological activity and increasing water solubility. This helps in excretion by the kidney.
Question 4

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Exogenous Cushing’s syndrome like any other medical condition requires attention and
careful monitoring of the patients. Nursing care plans, interventions and rationales are of
importance in ensuring the patient is well managed. Important nursing interventions involve
assessing the risks associated with the disease and helping prevent exposure of the patient to
more of these risks. In this medical case, it is important for the nurse to assess signs of
circulatory overload. This can be done by checking for respiratory crackles, cyanosis, edema
formation, distended neck veins and dyspnea (Bansal et al, 2015). This will assist in immediate
intervention as it would mean that the glucocorticoid levels are so high that they predispose the
patient to excessive water retention.
It is important for the nurse to monitor important vitals such as blood pressure levels and
heart rate. Exogenous Cushing’s syndrome is highly associated with elevated blood pressure and
therefore the rationale for this would be ensure that the patient is in a stable condition and offer
insight on the effectiveness of the medications given in managing the condition. The nurse may
also administer anti hypertensives where the blood pressure is highly elevated to control the
condition from worsening. It is important for the patient to be advised on low fluid intake and to
be given a healthy diet plan (Assié, 2018, June). Assessment of the skin frequently to look for
signs of redness and skin tearing is an important nursing intervention. This is because the
condition causes damage of important dermal proteins hence altering the skin integrity and
predisposing the patient to bruising and injury. It is important to manage this conditions
whenever detected.
Since the condition causes osteoporosis, it is important to assess the patient for decreased
height and kyphosis. This will help in monitoring progress of the patient in the healing process.
Since diabetes is a risk factor associated to Cushing’s syndrome, it is important to obtain

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information concerning any history of the disease and also incidences of poor wound healing so
as to aid in intervention process. Since the syndrome is associated with muscle loss and poor
body structure, it is important to encourage a high protein diet so that the patient maintains a
healthy body structure. Low carbohydrate intake should always be discouraged in any Cushing’s
disease as high cortisol levels elevate blood sugar (Gottiganti et al, 2017).
The disease predisposes individuals to the risk of contracting other infections. This is
because corticosteroids jeopardize the integrity of the immune system. It is necessary for the
nurse or care provider to closely monitor the patient for any signs of infection and act promptly
to ensure they are managed. According to Pereira et al. (2016), increased use of corticosteroids
associated with the syndrome can cause a fungal infection in the patient. It is therefore of
necessity for the nurse to inspect the patient for such signs and intervene. It is important to assess
the patient’s level of knowledge as far as the Exogenous Cushing’s syndrome is involved and
offer adequate health education where the knowledge is limited so as to prevent future recurrence
and also exacerbation of the condition.

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REFERENCES
Andela, C. D., van Haalen, F. M., Ragnarsson, O., Papakokkinou, E., Johannsson, G., Santos, A.,
... & Pereira, A. M. (2015). Mechanisms in endocrinology: Cushing's syndrome causes
irreversible effects on the human brain: a systematic review of structural and functional
magnetic resonance imaging studies. European journal of endocrinology, 173(1), R1-
R14.
Assié, G. (2018, June). Genomic insights into Cushing syndrome. In Annales d'endocrinologie
(Vol. 79, No. 3, pp. 119-122). Elsevier Masson.
Bansal, V., El Asmar, N., Selman, W. R., & Arafah, B. M. (2015). Pitfalls in the diagnosis and
management of Cushing's syndrome. Neurosurgical focus, 38(2), E4.
Gottiganti, G., Badhvel, J. K., Dornadula, G. R., Petam, A. K., & Pothugunt, B. C. (2017). Case
report on dexamethasone induced iatrogenic cushing syndrome. International Journal of
Pharmaceutical Sciences Review and Research, 45, 29.
Morgan, S. A., Hassan-Smith, Z. K., & Lavery, G. G. (2016). Mechanisms in endocrinology:
tissue-specific activation of cortisol in Cushing’s syndrome. European journal of
endocrinology, 175(2), R81-R87.
Nieman, L. K. (2018). Recent Updates on the Diagnosis and Management of Cushing's
Syndrome. Endocrinology and Metabolism, 33(2), 139-146.
O'brien, K. F., DeKlotz, C. M. C., & Silverman, R. A. (2018). Exogenous Cushing syndrome
from an unexpected source of systemic steroids. Pediatric dermatology, 35(3), e196-
e197.

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Pappachan, J. M., Hariman, C., Edavalath, M., Waldron, J., & Hanna, F. W. (2017). Cushing's
syndrome: a practical approach to diagnosis and differential diagnoses. Journal of
clinical pathology, 70(4), 350-359.
Pereira, M. T., Ferreira, L., Horta, A. A., & de Carvalho, A. C. (2016). Exogenous Cushing's
syndrome as a result of ritonavir–budesonide interaction–A case report. HIV & AIDS
Review, 15(2), 91-93.
Pineyro, M. M., Redes, L., De Mattos, S., Sanchez, L., Brignardello, E., Bianchi, V., ... & Viola,
M. (2019). Factitious Cushing's Syndrome: A Diagnosis to Consider When Evaluating
Hypercortisolism. Frontiers in Endocrinology, 10.
Pivonello, R., Isidori, A. M., De Martino, M. C., Newell-Price, J., Biller, B. M., & Colao, A.
(2016). Complications of Cushing's syndrome: state of the art. The Lancet Diabetes &
Endocrinology, 4(7), 611-629.
Rainsbury, P. G., Sharp, J., Tappin, A., Hussey, M., Lenko, A., & Foster, C. (2017). Ritonavir
and topical ocular corticosteroid induced Cushing’s syndrome in an adolescent with HIV-
1 infection. The Pediatric infectious disease journal, 36(5), 502-503.
Sharma, S. T., Nieman, L. K., & Feelders, R. A. (2015). Cushing’s syndrome: epidemiology and
developments in disease management. Clinical epidemiology, 7, 281.