Other Diagnostic Tests

• Imaging studies may be used to distinguish among pituitary, ectopic, and adrenal tumors (Table 45-5).

Table 45-6 First-Line Screening Tests in Patients With Characteristics of Cushing's Syndrome

Test

Rationale

T/pjcil FinriiriLj In

CusMng s lynd i o me

Comments

Collect uime eve* .«id measuie unbound twlMj) emrcbod tf kkrf-H'y.

U'inii'v cdiwl

Urinary free coittof QflWICr thjii 4 I inwA It» uppw (eierence limit ¡s<ndfejt«eci I'lnlMlVp -.yiiilofiir'

Values between I And 4 tiiflti [hi upper reference |i"i 1 sugtjes! either tUillin^'i ■jylXtlCmc.'1 or pseiido Crushing JyndrOflW

Fasy to perform hut ihouk) not be used jlone ilntf vffisilivily Jrti ipteifitüv depend on the asiùy uvd To<?.«lude puiodic hypMcatisolcflv 3 nsxp H!H -.rnvika be otjiainrni (wirti urlrkMyaadtlnlne measurement! lo assess (ofne^cwnciii oi tt*;«iiMiisi0 l^miiyjuiJvi Cushlnq'ssyndrome from obusiLy elevriiorlL n'jv-ewr. Iitlse poiithiç if otner pwvdfrCuihingrs sut«, physiologic stress, or pregnane y tjiifriicçjtiTO fdtotteastd renal fwïLtkwx tw yjheKwal liypeiiixri^Vfinn

Ovsfnighl low CK)* (lend-mrthasione suppftiytxi C«KMT]

Give I mg oral (le^eirtKOfieíl II 'v. then mea^iie pliimatofriwl;]! R 9 mi (lv IVXT morning

Deaaipethdsare ,H(liii¡nrsii;irtiii supposes nioiráig pijama co<rt5ol m normal irdiYiJuali

LjHenkite salivary cctfii^m

CcJIen salivary

COClBOl

Il m

Loss of ehr ad lari ihyltwn secretion (no rad" al ró^N) in Gwtilnfft syndrome bul ndiipsHxb Cmhiivj'iiiAt«

l"|jima ( oí luol greyer ihäft 14J nxq/flt {Jranal/I J h diagnostic loi iusMnq's íyfldicflne Ptesmícartlsd leS-S líun 1J nKyrtJL 131 nfllQl/L) Hi not suggesKve of CuvlMnq1! lylUjiCmi'

Simple to perlnrm ami Inexpensive

Can bi uwi) Ificonjunciiori wilh.or

Instead if, llw unary fm> coi risd tesl Caraho uw-1 he 2 (Jay ? rng KT Falsi positive if pseucioi usbing1* siiies, physiologic stress pregnancy, eshogen (madmen!, uremia, lakiny inducer! of dexame [hAiane metabolism (phiTi/icjin, etci of decreased dexamelhasone obit<pliOn fals? negative If subclinical hyppcoHliidisin or slow mttfaboliOT of

Diagnosis criteria need further vatdatton lasicsl screening <es1 to perform feampie can t»colkiW(i ai notiw by ihnienr} Can be died In conjunction with, or instead of, UVunmrylrcccjortiwl Mil

Mr deiamerhasone suppression resi. Fian ftefs. 2. 14, li.

In drug-induced Cushing's syndrome, discontinuation of the offending agent is the best management option. However, abrupt withdrawal of the glucocorticoid can result in adrenal insufficiency or exacerbation of the underlying disease.15 Glucocorticoid doses less than 7.5 mg/day of prednisone or its equivalent for less than

2 22

3 weeks generally would not be expected to lead to suppression of the HPA axis. ' However, in patients receiving pharmacologic doses of glucocorticoids for prolonged periods, gradual tapering to near physiologic levels (5-7.5 mg/day of prednisone or its equivalent) should precede drug discontinuation. Administration of a short-acting glucocorticoid in the morning and use of alternate-day dosing may reduce the risk of adrenal suppression. Testing of the HPA axis may be useful in assessing adrenal reserve. In some cases, supplemental glucocorticoid administration during excessive physiologic stress may be needed for up to 1 year after glucocorticoid discontinuation.15 Table 45-8 lists strategies to prevent the development of hypercortisolism and hypocortisolism.

Table 45-7 Pharmacologic Treatments for Cushing's Syndrome

Cru 5

iW#rluriim ni finug*'- Ir-rtuf Kh.ul. Mlitumjiti. flmingi tefrrinmn for Hwd wtl^rtigptrttc fnmiwi jod.'oi NJVT Wmtnaf Htactipni.

inmmoff ot admuï 5jet-akdogen«ls t ii -' Jdhj^liiUfiQ

«JrnMWltiQfil

ErrrtcWi'ÇV «SlTtwtiis'brt trKifciv.

cybKh-Lwrc-Hia enzymei nckidng I7J0 ^Jrte ■7 hycioiyUsL1-, a ut llfMrydwyiaef. Ns» ri-4.it v [holtfJcvoi lyrttwta

II KeKS II-

Adr«fioytlE Agifu

NfiBlflfV ki-JJ hWliTiéiïJdiP/nBSfc

Mtfw wJHi ll.fr tydWiyU» ÏMl r r« fc-. 11 ti i* K-1 l gum

Lh-iTi-JU' rKxJlAL-j jtkHMÇr* SiffMlVSri

MfO(r se>rtO IW 4W AtàgoriM* t r 11 rMi'iiriliHaXO Ii,0*0

AÎjtL 200 rTVJ lniCT-iUv. éûO-ffiM m&tt*t it cmi eMded itowv, HI t \[2<X1 n^ttay ki 2-2 di.kàHl oowl ftAffît Safayjhd ridhuUHiwa hù*rf no» bwi ftijtfeted [MnavHy rntljocted by tw and ctavrq *JftJrT>nt iikuu be LtMftJdetrei n hwl1 iw OfeUB IVi"jni] .-»-|j j'.irnrri nffl ngçdod h (tnjl faut

çivkifi .Vrvs. H1F fc-ijAlar rtu»H.»: vile, and iîwtos hpq not bwn *ïl.ïHhhid r^. Vi jH ¡'i "M'ix iJ ii-'iKirfKTrt'T.n .j'il ki^pi •. i-rf-i-H-, i-'hm^ p-.il*-m g luvr nef hw-n ffiagflfhKl

AJjîl Llnili^jEHnfcjliftppiience, 'A 1.7 ■ng.ti

Mmrttmiy ArAHrfc. "<jir>*xJ eifrclbmc» noi bre«

«yn—iinm fcfleravriy fflMbClnd n tfw tow »wdlh* n*c*K»*rt. LMi w chinça t* ¡KH<W fettKfeHk

«tolingi .vlp.ulrr^r.i mat be h fcfcjncy and

Swrdwavi

ARltt ï-4 «yAifHi }-* tJMJwJ JUWV9-15 'yJvr. n ï l(. .jV^y rJ L

ftJàf^i Safer jftd (flfeedwftHi i^wt ^ tn^yi rtUMitfirtl lïl lUl'ï ÎTH-lilXiU'iiJ i>l llK- iM-1 jÎkI il.rjBj jcif jïiiïrtc m jr bc hivdftl «i Mvn iï-x-j-j.-

Mrif flrtd '■.-'Ju'un Lf to 30 rivjfcyiiï* Mei^i^ijvxj iff çv ivfi. jnj

.nllrj-illl 1 J IIIHT 1.1 ll'^llkl.l.i II iTrifl 1.1V.1«.' 10' jElr-r.iiiktï ri r-.HU iIt.Iui '. Ikti i -lM j.HrLrtt"J

i"ivrn-i,i> wi-l cokfjm: rFonuTHuac-ckwlicm, d tnater^tKe, ¿rri IÛ'JI ■GyTKCOiMÎ UL IMlfc lAï ftj-KÏlon inparrTKrt; xv jdieria msiffictercy j(t fitph dmOmn Ifun WiimiiAijyi

Otft&plh vKl I "h m f riJT. M rift rf imLfnc imcy, u InifïikfKf, rJrÎï, hypcficmion IrïecIcciiJIe pjm raifn?a, WMrtlini nyccloiA

inr Hçiv-rJi I^Itjikv pnHflfllHdA

hi-kiiliViriL'i rtfiriilij liliil kiMfMig DKIIWI AdtftUl rrri/fiiEn-iï im"i ll'iro '■jlk'i'îi'l ië."-:'!h1

rvpVKiTnvm il"#fjpy

Q iiiUbM-uyi'.

fj&li.

Iff] in.l 'llhriilbt.

liJi

.ilK.rlil

«HTlbfyQCCWk' fiQflMCi^t

I fi»--, tr«- in ai nutoihv of i,i|>.| ifiriiijJ mpuHïfnffït -uvn

W5nror efficacv widi uvurv cortlwl

Mooiw tvd II jVjmirL^^ for TtfillL'Qpjlily

LW'J In iwc»rsen w^h hiutwi afd

-ylk'iih wrtli i-ypeil0ckmU Rpqui«. ¡jjsjiic oOàf\y for i^&siufcn rid jbwirlWL jr«j Ihewfofv roi jw\II m pm!^'!1-

■3T hkfjTprr-j nftipfcf bockn fi fi.ni eij-idwHYJ:'. KKC^ ATTH

^njnsmf1. fi m i-iL'it cwJmma

Afr:: .-HU frt.1 Ii-ir DJdIhjftr*'- JChTki iHullkCftiy

WrcstlE-oÎ iJlTil-ibluiicri imm

.-4j--r.ir 'y-rd |r- r-llvr typin ^ Dwrintf^ WPChiKTïT EHt-ily likS vrA'il wM4ci l^lf fli iHlÇ'r^" wV-ll l.-Ji1 H ilfl j4llifojr l.il^-.mi ah i "■ïnl.'i-i ' iyïiî irj.-i jki ihmf^c ikmit rjîc u1 IftrfV WhHliïri

AeQum iiurtOtV UîC Wti tftif (Ihtjl ji si no l.icHihiyrK .ii 1 «rti^Ti .-n-jdL11fcj irï.HilM fffk.jpk.]r JÎ I IÎMI'I KTII

Km. "r|li-r»Vi"i ki ■ Jii Va. li JiMiT.1' iH I '--Wla i "h ¡{i i'i. NTE. r*M !■" f'ii i-'-i"

T hew rTKlii ifHWrt 1V1 fh'M h.rvi1 F 154. rt lirjlk. if S kl" 1 <il finJ-iHj'-!. hyTalkW» h r-llWi ,iiihs iV ;Nilli-',

Table 45-8 Principles of Glucocorticoid Administration to Avoid Hypercortisolism or Hypo-

cortisolism

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How To Deal With Rosacea and Eczema

Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.

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