Mary Cushing Syndrome: Causes, Incidences, Risk Factors, and Impact on Patient and Family

This article provides an overview of Mary Cushing Syndrome, including its causes, incidences, risk factors, and impact on the patient and their family. It also discusses the signs and symptoms of the syndrome and the pharmacodynamics and pharmacokinetics of drugs used to treat it.

MARY CUSHING SYNDROME
1. Exogenous Cushing syndrome
Causes
This is a condition which mostly occurs due to excess exposure to high cortisol level for a long
time. Cortisol is a hormone which is made by the adrenal gland and it is responsible for
managing stressful situations in the body such as illness. Too much cortisol causes Cushing's
syndrome regardless of the cause. Adrenal tumors are one of the causes of increased production
of cortisol in the body but in this case study, MS Mary Smith has been on cortisol treatment for 9
years since she was 15 years due to rheumatoid arthritis and has been experiencing multiple
exacerbations that required high doses of oral corticosteroids.
Incidences
Cushing's syndrome is not common and it is often found in women than in men and mainly
occurs between ages 20 and 40, exogenous Cushing syndrome is drug-induced and is commonly
seen in the clinical setting. Its clinical manifestations are more prominent and gradual than of
endogenous Cushing syndrome.
Risk factors
This is health problems that result from exogenous Cushing syndrome: a low immune system
which predisposes the patient to frequent infections, damage to the nerves of the eyes, kidney
due to untreated high blood sugar, high cholesterol level, and Diabetes. Mary has been diagnosed
with diabetes and she is currently under medication which is a risk factor of the underlying
disease. Risk factors can also be factors that increase the risk of Cushing syndrome and they

include type 2 diabetes, poorly controlled blood sugar levels which still cause retinopathy and
nephropathy and high blood pressure resulting from the glucocorticoids or adrenocorticotrophic
hormone administration.
Impact of the disease to patient and family
Majority of patients said about how Cushing syndrome has affected their everyday life and effect
on their families at work and both at school. Quality of life is increasingly impaired in patients
with this disease regardless of treatment strategies and patients with Cushing syndrome report
more negative perception than those other patients with acute and chronic illnesses. Patient
experienced mental problems such as depression, anxiety, anger, and hostility mostly due to the
disease process and hospitalization, these conditions affect patient's concentration and even
memory. Patients with this disease also experienced low self-esteem due to impaired body shape
especially deposits of fat in the abdomen and round face. Patients experience pain. Patients with
this condition also experience complications for example kidney failure due to damage to its
nerves. This disease imposes a burden to the family caregivers and even others. Families
experienced psychological and non-health effects. They include changes in their daily activities,
some even didn't go for work to take care of the patient. Families had to even sell some of their
properties or raise money for payment of bills of a loved one who is sick.
2. Signs and symptoms
Signs and symptoms Pathophysiology
Weight gain Weight gain often occurs at the trunk and not
accompanied by weight gain in the arms and
the legs. High level of cortisol in the body

leads to redistribution of fats to the chest and
stomach area. This goes hand in hand with
rounding of the face, becomes puffy and red.
A "buffalo hump" develops due to the
accumulation of fats in the shoulders and the
neck. Because cortisol level will be more than
normal it will require more carbohydrate. So
cortisol metabolizes the food and refuels the
body even when there is no requirement
within the body thus leading to weight gain.
(Wilson, 2017)
Skin changes The skin thins because cortisol causes
breakdown of dermal proteins responsible for
hardening and thickening of the skin, it also
weakens blood vessels.it weakens the skin
such that it becomes shiny, a paper-thin
quality which allows it to be torn so easily
thus it bruises easily. Reddish-purplish stretch
marks called striae appear commonly on the
stomach, thighs, arms limbs, breast and
buttocks, this is because Cushing syndrome
stretches the skin which is already thin due to
cortisol causing it to hemorrhage and stretch

so permanently, healing by
fibrosis(Williams,2015). Spots develop on the
chest, shoulders, and face due to acne as hair
follicles plug oil and dead skin which clog
skin pores leaving dark spots. Darkened skin
appears on the neck due to prolonged
exposure to cortisol which causes
hyperpigmentation. Edema and water
retention occurs within the skin due to excess
fluid buildup in the lower legs and feet as a
result of medication and underlying disease.
Minor injuries take long to heal, minor like
insect bites, cuts, and scratches because
corticosteroids impair wound healing and
surgical morbidity. (Guifarro, 2017)
Hypertension It results from the coordination of several
pathophysiologic mechanisms which includes
stimulation of mineralocorticoid and
glucocorticoid receptors as well as insulin
resistance causing elevation of cardiac output
and peripheral resistance because e they are
the determinants of arterial pressure.
Increased cardiac output resulting from

sympathetic dysfunction is said to be the
major trigger of hypertension. Cortisol
increases the concentration of erythropoietin.
Erythropoietin is direct.
Vasoconstrictor which causes an increase in
blood pressure which in turn causes
hypertension.it is the common cause of death
of patients. (Isidori, 2015)
3. Pharmacodynamics and pharmacokinetics of drugs used to treat
Corticosteroids (prednisolone)
It binds to cell receptors specifically cytoplasmic receptors and inhibits DNA synthesis, when
hormone-receptor occurs it either inhibit transcription from those genes thus its action is to
modulate gene expression in a specific target cell. Side effects include infections, heartburn, and
insomnia. Its pharmacokinetics is that it is active drug pharmacologically which is converted to
its active form in the liver. This drug is administered orally and it is rapidly absorbed after an
oral administration. It has a half-life of 1-3 hours. Its bioavailability is approximately 80%, it can
have impaired absorption in some individual with some conditions such as liver disease. Increase
in the dose of prednisolone causes a significant increase in plasma concentration thus it does not
bind to plasma proteins thus there should be reduced doses in patients with conditions such as
hypoalbuminemia. Prednisolone is also dependent on age; its half-life is shorter in children. It
has a pharmacokinetic drug interaction with anticonvulsants such as barbiturates.it is excreted in
urine as free and conjugated metabolites.

Metformin
Metformin decreases glucose production by decreasing hepatic glucose production, it does this
by decreasing intestinal glucose absorption by improving insulin receptors sensitivity to glucose
and also by increasing peripheral uptake of glucose and utilization in the body system.it has
some side effect for example diarrhea, flatulence, and lower blood sugar level.Metformin has an
oral bioavailability of 40 to 60% and it completely absorbed after 6hours of ingestion, it is
absorbed in tubules of the kidney and it is excreted unchanged in the urine, its half-life is
approximately 6hours. Metformin is detected in the plasma within 24hours of ingestion of single
dose..This drug is contraindicated in patients with renal disease.
4
Assessme
nts
diagnosis Goal/
outcome
interventi
ons
Rationale implementa
tion
Evaluati
on
Edema A risk for
excess fluid
overload
related to
water
retention of
water and
sodium
caused by an
excess of
cortisol and
After the
8hours of
nursing
interventio
n, Mary
will be
stable
weight,
balanced
fluid
intake, and
Carry out
fluid
intake
and
output.
Asses any
sign of
To ensure that
there is
balanced fluid
intake. For
early detection
of circulatory
overload so
that it can be
treated
immediately.
Cushing
The nurse
carried out
the fluid
intake and
output and
documented
The nurse
was able to
check for
signs of
circulatory
After
8hours
of
nursing,
intervent
ion
patient
had a
stable
weight
and

mineralocorti
coid levels
output,
reduction
of
edema, .sh
e will be
able to
show no
signs of
pulmonary
congestion
.
circulator
y
overload
Monitor
vital
signs
such as
blood
pressure
every 4
hours.
Monitor
the
patient's
sodium
and
potassium
level.
Instruct
the
patient to
reduce
fluid
syndrome may
result in
increased
blood pressure
thus it should
be monitored.
Mineralocortic
oids regulate
sodium and
potassium
secretion and
also excess
levels as
evidenced by
water
retention and
also
hypokalemia.
This help
reduce fluid
overload and
especially
prevent
overload
The nurse
monitored
vital signs
every
4hours and
documented
.
Electrolyte
level was
monitored
reduced
edema

patient. circulatory
overload
Skin
reddens
Bruises
on the
skin
The risk of
injury related
to decreased
bone density,
weak
muscles, and
poor wound
healing
After 8
hours of
nursing
interventio
n, patients
will be
free of
fracture or
soft tissue
injury.
The
patient
will be
able to
verbalize
on
measures
to prevent
injury
Asses the
skin
frequentl
y for
reddened
areas,
skin
breakdow
n or
bruises.
Asses
patient
for signs
of
kyphosis
or
decreased
height
Cushing
syndrome
cause thinning
of skin due to
cortisol as it
causes
damage of
dermal
proteins and
weakening of
blood vessels
thus the skin
becomes very
weak and easy
to be
damaged.
Due to weak
bone density,
spinal
compression
can easily
Nurse
assessed the
skin of the
patient for
any sign of
redness or
bruises.
Nurse
encourage
patient on
ways of
preventing
injury.
After
8hours
of
nursing
intervent
ion
patient
was free
of
fracture
and was
able to
verbalize
on ways
of
preventi
ng injury
to herself

occur and it
causes
fractures
which cause
decreased
height.
Risk for
infection
related to
altered
protein
metabolism,
high serum
cortisol level,
and impaired
immune
response
The
patient
will be
able to
verbalize
on
interventio
ns to
prevent
risk for
infection.
The
patient
will be
able to
display the
absence of
Asses for
signs of
infections
and also
patient to
avoid
unnecessa
ry
exposure
to people
with
infections
Stress
proper
hand
washing
technique
Cortisol
suppresses the
immune
system thus
patient will be
prone to
frequent
infections and
also
corticosteroids
show signs of
inflammation
and infection.
Hand washing
serves as the
first line of
defense
Nurse
assessed for
a sign of
infection
such as
taking body
temperature
and white
blood cell
and it was
documented
.
After
8hours
of
nursing
intervent
ion
patient
was free
of
infection

infection
that will
be
evidenced
by normal
body
temperatur
e and also
normal
white
blood cell
count.
s against
nosocomial
infections

References.
Guifarro, M. R., Chavez, J., Guifarro, D., Martinez, E., Figueroa, A., & Orellana, I. (2017).
IATROGENIC CUSHING'S SYNDROME PRESENTING SEVERE ATIPICAL SKIN
LESIONS EXTENDED IN THE BODY. Endocrine Practice, 23, 21.
Isidori, A. M., Graziadio, C., Paragliola, R. M., Cozzolino, A., Ambrogio, A. G., Colao, A., ... &
Pivonello, R. (2015). The hypertension of Cushing's syndrome: controversies in the
pathophysiology and focus on cardiovascular complications. Journal of hypertension,
33(1), 44.
Markowicz-Piasecka, M., M Huttunen, K., Mateusiak, L., Mikiciuk-Olasik, E., & Sikora, J.
(2017). Is metformin a perfect drug? Updates in pharmacokinetics and
pharmacodynamics. Current pharmaceutical design, 23(17), 2532-2550.
Paul, E. M., Jose, S., Achar, Y., & Raghunath, B. D. (2016). Prednisolone Induced Cushing
Syndrome: A Case Report. Indian Journal of Pharmacy Practice, 9(2), 141.
Williams, D. M. (2018). Clinical Pharmacology of Corticosteroids. Respiratory Care, 63(6),
655-67.
Wilson, D. P., Hamilton, L., Prakash, S., Castro-Silva, F. J., & Friedman, J. (2017).
Dyslipidemia, weight gain, and decreased growth velocity in a 14-year-old male. Journal
of clinical lipidology, 11(2), 562-566.