I would like to give my analysis of the below mentioned blog made by Dr. K. Vaishnavi ma'am with respect to my bimonthly blended assignemnt.

https://karnativaishnavi.blogspot.com/2021/08/cushings-syndrome.html?m=1

My analysis is mainly with respect to the following aspects:-

1. What is the evidence of topical preparations of glucocorticoids causing Cushing's syndrome? Is it more as compared to oral or similar? Do other modes of administration have the same effects?

2. Evidence of the laboratory investigations used in the diagnosis of Cushing's syndrome.

3. Efficacy of the therapeutic interventions mentioned for this patient?


Addressing the 1st issue-

1. In this patient, order of priority of his problems according to me are as follows:

  • Itchy, ring like lesions over trunk, arms, thigh and groin since 1 year
  • Purplish stretch marks over abdomen, limbs since 1 year
  • Facial puffiness and weight gain
  • Feeling low, not talking to anyone 
  • Low back ache
  • Pedal edema 
  • Loss of libido, erectile dysfunction
All his findings are classic of CUSHING'S SYNDROME.

A) Itchy ring like lesions over trunk, arms, thigh and groin: Suggestive of TINEA CORPORIS ET CRURIS

After going through the detailed analysis of the above mentioned blog, I think that this is the most important problem because this was the reason why he developed CUSHING'S SYNDROME in the first place.

He used CLOBETASOL OINTMENT over these lesions for approximately 1 year.

"The risk increases based on factors that include glucocorticoid potency (see Table I), the amount applied (affected body surface area is a surrogate measure), skin thickness and location (with eyelid and scrotum showing most penetration and the side of the foot the least), the presence of broken skin, the age of the patient (children have increased absorption), the use of occlusive dressings (which promote absorption), the type of vehicle (ointments increase penetration), and the duration of use. Cushing’s syndrome has been reported most often in infants receiving a class 1 agent (usually clobetasol)"

Although low doses of over-the-counter topical glucocorticoids are used commonly and safely, it is known that systemic absorption of steroids from topical preparations does occur and that at higher doses or with more potent preparations both adrenal axis suppression and Cushing’s syndrome can occur.

"https://www.saem.org.ar/departamentos/departamento-neuroendocrinologia/cushing-exogeno.pdf"

"It is now clear that significant systemic effects of inhaled corticosteroids can be seen, although fewer than with equivalent oral doses. These effects are dose-related and come in the form of adrenal suppression and Cushingoid stigmata, particularly bone, ocular, and skin manifestations."

B) Feeling low, not feeling like talking to anyone- suggestive of depression

Depression, mood dysregulation, sleep disturbance and cognitive abnormalities are also observed in Cushing’s syndrome. The rates for each of these symptoms vary widely across studies. Depression is the most prevalent psychiatric disturbance in Cushing’s syndrome. A major depressive syndrome is seen in 50%–70% of the cases. Other associated features include anxiety in 12%–79% of the cases, as well as a rate of 3% for hypomania. Less common are features of psychosis and mania.

"Glucocorticoid signalling insufficiency hypothesis suggests that hypercortisolaemia is an attempt to overcome primary glucocorticoid receptor resistance related to down-regulated glucocorticoid receptors. In contrast, the glucocorticoid signalling overactivity hypothesis for depression suggests there is overall increased net signalling via the glucocorticoid receptor. Changes in cortisol activity leading to decreased serotonin and increased dopamine cerebral activity have also been described."

Addressing the 2nd issue:

The following study was done to check for the sensitivity of SLEEPING MIDNIGHT CORSTISOL in the diagnosis of Cushing's syndrome:

https://pubmed.ncbi.nlm.nih.gov/8548938/

"The aim of this study was to compare the sensitivity in the diagnosis of Cushing's syndrome of a single in-patient sleeping midnight cortisol to a standard 48-hour in-patient low-dose dexamethasone suppression test (LDDST) during the same admission.

In this series of 150 cases, a single in-patient sleeping midnight cortisol above 50 nmol/l had a 100% sensitivity for the diagnosis of Cushing's syndrome, clearly different from normal subjects. In contrast, the low-dose dexamethasone suppression test had a sensitivity of 98% even when the drug was administered as an in-patient. We recommend that a low-dose dexamethasone suppression test should not be used alone for confirmation of Cushing's syndrome since it may miss 2% of cases."

Efficacy of various investigations in the diagnosis of Cushing's syndrome:


https://www.scielo.br/j/abem/a/5hLj3WwC8CN6ctNdNn9Cyzg/?lang=en#

Addressing the 3rd issue-

The patient in our case received:

  • TAB. HISONE
  • INJ. HYDROCORTISONE (in cases of adrenal crisis)

Treatment of exogenous cushing's syndrome is to decrease and eventually stop taking any corticosteroids which was also done in our patient. Suddenly stopping corticosteroids after taking them for a long time (usually more than 2 weeks) can result in a life-threatening condition called adrenal crisis.

Inspite of tapering the dose of medication, his symptoms did not subside.

Therefore, a probability of DOUBLE CUSHING'S SYNDROME was suspected. Though it is a very rare diagnosis, it should be considered in patients whose Cushing's syndrome related symptms do not subside even after stopping the steroid medication.

I would suggest that our patient should undergo the following workup in case there is an endogenous Cushing's syndrome.

                                                      

References:




4. https://www.scielo.br/j/abem/a/5hLj3WwC8CN6ctNdNn9Cyzg/?lang=en#  

5. Harrison's principles of internal medicine

6. https://emedicine.medscape.com/article/117365-followup#e4



The following is a case report of a patient who I closely followed up on in the past month:

https://rhea9895.blogspot.com/2022/01/29-years-old-female-with-co-joint-pains.html



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