1. Cushing’s syndrome
一40岁女性，自述近两年体重增加，尤其腹部，但体力却明显下降。到当地医院就诊时发现血压高、血糖高、血脂高、血钾低，对症治疗不见好转来诊。你考虑该患可能得了什么病？线索？为什么？还应做那些检查？
鉴别：2型糖尿病：类固醇性糖尿病：小剂量地塞米松抑制试验被抑制
代谢综合征：

2. Effects of glucocorticoid
Effects on metabolism
Effects on immunologic function and inflammatory
Effects on musculoskeletal and connective tissues
Effects on fluid and electrolyte homeostasis
Neuropsychiatric and behavioral effects
Gastrointestinal effects
Developmental effects

3. Clinical features
Obesity (The increased fat distribution is not generalized)
Moon-shaped face and plethoric
Purple striae
Hypertension
IGT
Osteoporosis
Hypokalemic alkalosis

4. The hypothalamic-pituitary-adrenal axis
Hypothalamus
Nyctohemeral
rhythm
CRH
Neural stimuli
Anterior pituitary
Negative
feedback
ACTH
Adrenal cortex
Cortisol  Cortisol
(CBG bound) (free)
Physiological and
Metabolic effects
Plasma
Inactivation by reduction and conjugation
Liver
Urine
Tetrahydrocortisol
Tetrahydrocortisone
Cortols,Cortolones
(measurd as urinary 17-OHCS)
Unchanged cortisol
(measured as urinary free cortisol)
The hypothalamic-pituitary-adrenal axis

5. Suspected Cushing’s synd. Suspected Cushing’s synd.
Plasma cortisol
Urinary free cortisol
Urinary 17-OHCS 
Low dose dexamethasone suppression test
2.0mg/day2days
<50% reduce from basal
>50% reduce from basal
Cushing’s Synd.
NORMAL
High dose dexamethasone suppression test
8.0mg/day2days
>50% reduce from basal
<50% reduce from basal
Plasma ACTH 
Adrenal Disease
Ectopic ACTH Synd.
Probable
Cushing’s Disease

6. Probable Ectopic ACTH Synd. Probable Adrenal Disease
Plasma ACTH
Increased
Low
Probable Ectopic ACTH Synd.
Probable Adrenal Disease
Tumor Search
CT /MRI Scan of Adrenals
positive
negative
normal
adrenal mass
urinary 17-KS
Plasma DHEA
ECTOPIC
ACTH
SYNDROME
Consider
Adrenonodular
Hyperplasia,
Other Disorders
17-KS DHEA 
DHEA 
17-KS  
ADRENAL
ADENOMA
ADRENAL
CARCINOMA

7. hypothalamus pituitary
Drugs:
Cyproheptadine
Metergoline
Bromocryptine
Surgery
Radiation
hypothalamus
CRH
Surgery:
Transsphenoidal microsurgery
Radiation:
60Co
linear accelerator
pituitary
ACTH
赛更定Cyproheptadine（血清素抑制剂）
麦角苄脂Metergoline
双氯苯二氯乙烷（米托坦）o,p’DDD(mitotane)（束、网状带萎缩）
美替拉酮Metyrapone（抑制CS合成）
氨基导眠能Aninoglutethmide（抑制CS合成）
酮康唑ketokonazole（减少CS合成）
Drug:
o,p’DDD(mitotane)
Metyrapone
Aninoglutethmide
ketokonazole
Adrenalectomy
adrenal
TREATMENT CS

8. Oat cell carcinoma of lung
A 45-year-old man complaints of severe weakness. He appears chronically wasted and is mildly hyperpigmented. His blood pressure is 160/100mmHg. A high-dose dexamethasone suppression test (2 mg every 6 h) causes no suppression of urinary free cortisol, 17-hydroxycorticosteroids (17-OHCS ,or 17-ketosteroids(17-KS). The most appropriate diagnosis Is
Oat cell carcinoma of lung

9. A 26-year-old woman complaints of irregular menses, obesity, and low back pain. She has mild hypertension, central obesity, broad striae, acne, and mild hirsutism. A low-dose dexamethasone suppression test causes no suppression of urinary free cortisol and 17-OHCS. A high-dose dexamethasone suppression test causes greater than 50 percent suppression of urinary free cortisol and 17-OHCS. The most appropriate diagnosis is
Cushing’s disease

10. 3. A 28-year-old woman complaints of weakness, easy bruising, hirsutism, and irregular menses. She exhibits moon face, central obesity, and severe hirsutism involving the face and trunk, but no virilism. A high-dose dexamethasone suppression test causes no suppression of free cortisol, 17-OHCS, or 17-KS. Plasma dehydroepiandrosterone(DHEA) sulfate is fourfold normal. The most appropriate diagnosis is
Adrenal carcinoma

11. Congenital adrenal hyperplasia
4. A 15-year-old boy complaints of short stature.He has history of early sexual development and accelerated growth that ceased 5years ago.He displays hyperpigmentation. A high-dose dexamethasone suppression test causes greater than 50 percent suppression of urinary 17-KS. The most appropriate diagnosis is
Congenital adrenal hyperplasia

12. Laboratory values serum plasma urine Cortisol K+ HCO3 ACTH 17-OHCS
at 8 A.M.
(ug/100 ml) K+
(mmol/L )
HCO3
(mmol/L )
ACTH
(PG/100ML)
17-OHCS
(mg/24h)
17-KS
(mg/24h) 1. 2. 3. 4.
3.0
3.9
3.2
3.8 35 25 32 40 20 80 13
1000 90 5
250 35 15 4 40 15 70 65
Normal: cortisol:10-24,; ACTH:40-100; OHCS:3-12; KS: 5-20