Endogenous Cushing Syndrome Differential Diagnoses

Sections

DDx

Diagnostic Considerations

Diagnosis of Cushing syndrome can sometimes be very challenging, especially in cases of pseudo-Cushing, subclinical, mild or cyclic Cushing syndrome.

A pseudo-Cushing is defined as having some of the clinical features and biochemical evidence of Cushing syndrome. However, resolution of the primary condition results in disappearance of the cushingoid features and biochemical abnormalities.

In patients who chronically abuse alcohol, clinical and biochemical findings suggestive of Cushing syndrome are often encountered. Discontinuation of alcohol causes disappearance of these abnormalities, and, therefore, this syndrome is often specifically referred to as alcohol-induced pseudo-Cushing syndrome. Patients with depression often have perturbation of the HPA axis, with abnormal cortisol hypersecretion. These patients rarely develop clinical Cushing syndrome. Because excess glucocorticoids can lead to emotional liability and depression, distinguishing between depression and mild Cushing syndrome is often a diagnostic challenge.

See Pseudo-Cushing Syndrome.

Differential Diagnoses

Alcoholism
Anorexia Nervosa
Bulimia Nervosa
Concurrent ritonavir and inhaled fluticasone in patients with HIV - Interferes with dexamethasone suppression testing (false positive)
Depression
Obesity
Pseudo-Cushing Syndrome
Psychiatric Illness

Workup

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Media Gallery

Physical findings in Cushing syndrome.
Diagnosis of Cushing syndrome.
Etiology of Cushing syndrome.
High power H and E of a pituitary adenoma showing a monotonous proliferation of bland cells. Not all pituitary adenomas result in Cushing syndrome, only those that produce ACTH.
Intermediate power H and E of an adrenal adenoma showing a monotonous proliferation of bland cells. Not all adrenal adenomas or carcinomas result in Cushing's syndrome; only those that produce ACTH.

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Table. States of Elevated and Low Plasma Cortisol

Table. States of Elevated and Low Plasma Cortisol

States of Elevated Plasma Cortisol	States of Low Plasma Cortisol
Chronic stress Melancholic depression Anorexia nervosa Obsessive-compulsive disorder Panic disorder Excessive exercise Chronic active alcoholism Alcohol and nicotine withdrawal Diabetes mellitus Central obesity Sexual abuse (stress) Hyperthyroidism Premenstrual tension syndrome Cushing syndrome Pregnancy	Adrenal insufficiency Atypical/seasonal depression Chronic fatigue syndrome Fibromyalgia Hypothyroidism Post-glucocorticoid therapy Post-Cushing syndrome Postpartum period Post-chronic stress Rheumatoid arthritis

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Author

Ha Cam Thuy Nguyen, MD Fellow, Department of Endocrinology, University of Pittsburgh Medical Center

Ha Cam Thuy Nguyen, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Medical Association, Endocrine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Catherine Anastasopoulou, MD, PhD, FACE Associate Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University; Attending Endocrinologist, Department of Medicine, Albert Einstein Medical Center

Catherine Anastasopoulou, MD, PhD, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, American Society for Bone and Mineral Research, Endocrine Society, Philadelphia Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Gail K Adler, MD, PhD, Associate Professor of Medicine, Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School.

Disclosure: Nothing to disclose.

Susanna L Dipp, MD Fellow, Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School

Disclosure: Nothing to disclose

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Disclosure: Nothing to disclose

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