Addison's disease

Addison's disease is a disorder that occurs when the adrenal glands do not produce enough of their hormones. Addison's disease is a disorder that occurs when your body produces insufficient amounts of certain hormones produced by your adrenal glands. In Addison's disease, your adrenal glands produce too little cortisol and often insufficient levels of aldosterone as well. Also called adrenal insufficiency, Addison's disease occurs in all age groups and affects both sexes. Addison's disease can be lifethreatening. Treatment for Addison's disease involves taking hormones to replace the insufficient amounts being made by your adrenal glands, in order to mimic the beneficial effects produced by your naturally made hormones.

CAUSES The adrenal glands are small hormone-releasing organs located on top of each kidney. They are made up of the outer portion (called the cortex) and the inner portion (called the medulla). The cortex produces three types of hormones: The glucocorticoid hormones (such as cortisol) maintain sugar (glucose) control, decrease (suppress)immune response, and help the body respond to stress. The mineralocorticoid hormones (such as aldosterone) regulate sodium and potassium balance. The sex hormones, androgens (male) and estrogens (female), affect sexual development and sex drive.

Addison's disease results from damage to the adrenal cortex. The damage causes the cortex to produce less of its hormones. This damage may be caused by the following: The immune system mistakenly attacking the gland (autoimmune disease) Infections such as tuberculosis, HIV, or fungal infections Hemorrhage, blood loss Tumors Use of blood-thinning drugs (anticoagulants)

Risk factors for the autoimmune type of Addison's disease include other autoimmune diseases: Chronic thyroiditis Dermatis herpetiformis Graves' disease Hypoparathyroidism Hypopituitarism Myasthenia gravis Pernicious anemia Testicular dysfunction Type I diabetes Vitiligo

Certain genetic defects may cause these conditions. Addison's disease results when your adrenal glands are damaged, producing insufficient amounts of the hormone cortisol and often aldosterone as well. These glands are located just above your kidneys. As part of your endocrine system, they produce hormones that give instructions to virtually every organ and tissue in your body.

Your adrenal glands are composed of two sections. The interior (medulla) produces adrenaline-like hormones. The outer layer (cortex) produces a group of hormones called corticosteroids, which include glucocorticoids, mineralocorticoids and male sex hormones (androgens). Some of the hormones the cortex produces are essential for life the glucocorticoids and the mineralocorticoids. Glucocorticoids. These hormones, which include cortisol, influence your body's ability to convert food fuels into energy, play a role in your immune system's inflammatory response and help your body respond to stress. Mineralocorticoids. These hormones, which include aldosterone, maintain your body's balance of sodium and potassium to keep your blood pressure normal. Androgens. These male sex hormones are produced in small amounts by the adrenal glands in both men and women. They cause sexual development in men and influence muscle mass, libido and a sense of well-being in both men and women. Primary adrenal insufficiency Addison's disease occurs when the cortex is damaged and doesn't produce its hormones in adequate quantities. Doctors refer to the condition involving damage to the adrenal glands as primary adrenal insufficiency. The failure of your adrenal glands to produce adrenocortical hormones is most commonly the result of the body attacking itself (autoimmune disease). For unknown reasons, your immune system views the adrenal cortex as foreign, something to attack and destroy. Other causes of adrenal gland failure may include: Tuberculosis Other infections of the adrenal glands Spread of cancer to the adrenal glands Bleeding into the adrenal glands Secondary adrenal insufficiency Adrenal insufficiency can also occur if your pituitary gland is diseased. The pituitary gland makes a hormone called adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex to produce its hormones. Inadequate production of ACTH can lead to insufficient production of hormones normally produced by your adrenal glands, even though your adrenal glands aren't damaged. Doctors call this condition secondary adrenal insufficiency. Another more common cause of secondary adrenal insufficiency occurs when people who take corticosteroids for treatment of chronic conditions, such as asthma or arthritis, abruptly stop taking the corticosteroids.

Addisonian crisis
If you have untreated Addison's disease, an addisonian crisis may be provoked by physical stress, such as an injury, infection or illness. SYMPTOMS Changes in blood pressure or heart rate Chronic diarrhea, nausea, and vomiting, or loss of appetite resulting in weight loss Darkening of the skin in some places, causing the skin to look patchy Paleness Extreme weakness, fatigue, and slow, sluggish movement Mouth lesions on the inside of a cheek (buccal mucosa) Salt craving

Addison's disease symptoms usually develop slowly, often over several months, and may include: Muscle weakness and fatigue Weight loss and decreased appetite Darkening of your skin (hyperpigmentation) Low blood pressure, even fainting Salt craving Low blood sugar (hypoglycemia) Nausea, diarrhea or vomiting Muscle or joint pains Irritability Depression Body hair loss or sexual dysfunction in women

Acute adrenal failure (addisonian crisis) Sometimes, however, the signs and symptoms of Addison's disease may appear suddenly. In acute adrenal failure (addisonian crisis), the signs and symptoms may also include: Pain in your lower back, abdomen or legs Severe vomiting and diarrhea, leading to dehydration Low blood pressure Loss of consciousness High potassium (hyperkalemia)

When to see a doctor See your doctor if you have signs and symptoms that commonly occur in people with Addison's disease, such as: Darkening areas of skin (hyperpigmentation) Severe fatigue Unintentional weight loss Gastrointestinal problems, such as nausea, vomiting and abdominal pain Dizziness or fainting Salt cravings Muscle or joint pains Your doctor can help determine whether Addison's disease or some other medical condition may be causing these problems.

EXAMS AND TESTS Tests may show: Increased potassium Low blood pressure Low cortisol level Low serum sodium Normal sex hormone levels

Other tests may include: Abdominal x-ray Abdominal CT scan

This disease may also change the results of the following tests: 17-hydroxycorticosteroids 17-ketosteroids 24-hour urinary aldosterone excretion rate ACTH Aldosterone Blood eosinophil count CO2 Cortrosyn stimulation test Potassium test Renin Urine cortisol

Treatment with replacement corticosteroids will control the symptoms of this disease. However, you will usually need to take these drugs for life. People often receive a combination of glucocorticoids (cortisone or hydrocortisone) and mineralocorticoids (fludrocortisone). Never skip doses of your medication for this condition, because life-threatening reactions may occur. The health care provider may increase the medication dose because of: Infection Injury Stress Surgery

During an extreme form of adrenal insufficiency, called adrenal crisis, you must inject hydrocortisone immediately. Supportive treatment for low blood pressure is usually needed as well. Some people with Addison's disease are taught to give themselves an emergency injection of hydrocortisone during stressful situations. It is important for you to always carry a medical identification card that states the type of medication and the proper dose you need in case of an emergency. Your health care provider may also tell you to always wear a Medic-Alert tag (such as a bracelet) alerting health care professionals that you have this condition in case of emergency. Outlook (Prognosis) With hormone replacement therapy, most people with Addison's disease are able to lead normal lives. Possible Complications Complications can occur if you take too little or too much adrenal hormone supplement. Complications also may result from the following related illnesses: Diabetes Hashimoto's thyroiditis (chronic thyroiditis) Hypoparathyroidism Ovarian hypofunction or testicular failure Pernicious anemia Thyrotoxicosis

Tests and diagnosis Your doctor will talk to you first about your medical history and your signs and symptoms. If your doctor thinks that you may have Addison's disease, you may undergo some of the following tests: Blood test. Measuring your blood levels of sodium, potassium, cortisol and ACTH gives your doctor an initial indication of whether adrenal insufficiency may be causing your signs and symptoms. A blood test can also measure antibodies associated

with autoimmune Addison's disease.

ACTH stimulation test. This test involves measuring the level of cortisol in your blood before and after an injection of synthetic ACTH. ACTH signals your adrenal glands to produce cortisol. If your adrenal glands are damaged, the ACTH stimulation test shows that your output of cortisol in response to synthetic ACTH is limited or nonexistent.

Insulin-induced hypoglycemia test. Occasionally, doctors suggest this test if pituitary disease is a possible cause of adrenal insufficiency (secondary adrenal insufficiency). The test involves checking your blood sugar (blood glucose) and cortisol levels at various intervals after an injection of insulin. In healthy people, glucose levels fall and cortisol levels increase.

Imaging tests. Your doctor may have you undergo a computerized tomography (CT) scan of your abdomen to check the size of your adrenal glands and look for other abnormalities that may give insight to the cause of the adrenal insufficiency. Your doctor may also suggest a MRI scan of your pituitary gland if testing indicates you might have secondary adrenal insufficiency.

Treatments and drugs All treatment for Addison's disease involves hormone replacement therapy to correct the levels of steroid hormones your body isn't producing. Some options for treatment include: Oral corticosteroids. Your doctor may prescribe fludrocortisone to replace aldosterone. Hydrocortisone (Cortef), prednisone or cortisone acetate may be used to replace cortisol. Corticosteroid injections. If you're ill with vomiting and can't retain oral medications, injections may be needed. Androgen replacement therapy. To treat androgen deficiency in women, dehydroepiandrosterone can be prescribed. Some studies suggest that this therapy may improve overall sense of well-being, libido and sexual satisfaction. An ample amount of sodium is recommended, especially during heavy exercise, when the weather is hot, or if you have gastrointestinal upsets, such as diarrhea. Your doctor will also suggest a temporary increase in your dosage if you're facing a stressful situation, such as an operation, an infection or a minor illness.

Addisonian crisis
An addisonian crisis is a life-threatening situation that results in low blood pressure, low blood levels of sugar and high blood levels of potassium. This situation requires immediate medical care. Treatment typically includes intravenous injections of: Hydrocortisone Saline solution Sugar (dextrose)

Adrenal function The adrenal glands sit at the top of the kidneys, one on each side of the body and have an inner core (known as the medulla) surrounded by the outer shell (known as the cortex). The inner medulla produces adrenaline, the fight or flight stress hormone. While the absence of the adrenal medulla does not cause disease, the cortex is more critical. It produces the steroid hormones that are essential for life: cortisol and aldosterone. Cortisol mobilises nutrients, it enables the body to fight inflammation, it stimulates the liver to produce blood sugar and it also helps control the amount of water in the body. Aldosterone regulates salt and water levels which affect blood volume and blood pressure. The adrenal cortex also produces sex hormones known as adrenal androgens; the most important of these is DHEA. The normal adrenal cortex has an enormous functional reserve. This is called upon by the body especially in times of intense stress, such as surgery, trauma or serious infection. One of the most significant consequences of Addisons disease is, therefore, the bodys failure to adapt to such stresses and, in the absence of adequate steroid cover, this may result in a state of shock, known as an Addisonian crisis, which is a medical emergency.

Causes of adrenal failure Thomas Addison first identified the disease in 1855 while working at Guys Hospital in London. At that time, the main cause of the disease was as a complication of tuberculosis. TB still remains an important cause of Addisons in Third World countries. HIV (AIDS) is now becoming another significant infectious disease causing adrenal failure among third world population. In more affluent countries, the most frequent cause of Addisons disease is destructive atrophy whereby an over -active immune system starts attacking the bodys own organs; in this case, the adrenals. This accounts for around 70% of all cases and affects more women than men. In common with most other autoimmune diseases, the exact reason for the atrophy is unknown. Other, much rarer causes of Addisons include certain fungal infections, adrena l cancer and adrenal haemorrhage (for example, following a car accident). Symptoms Addisons disease is not usually apparent until over 90% of the adrenal cortex has been destroyed, so that very little adrena l capacity is left. This can take months to years and is known as primary adrenal insufficiency. Symptoms of the disease, once advanced, can include severe fatigue and weakness, loss of weight, increased pigmentation of the skin, faintness and low blood pressure, nausea, vomiting, salt cravings and painful muscles and joints. Because of the rather non-specific nature of these symptoms and their slow progression, they are often missed or ignored until, for example, a relatively minor infection leads to an abnormally long convalescence which prompts an investigation. Frequently, it is not until a crisis is precipitated that attention is turned to the adrenals. Secondary failure Secondary adrenal insufficiency is sometimes described as Addisons, although it has a very different cause. It mostly occurs when a pituitary tumour (such as an adenoma) forms, although autoimmune destruction of the pituitary gland is also known. In secondary adrenal insufficiency, the pituitary gland no longer triggers the adrenals to produce cortisol, and DHEA production is also believed to decline. In most cases of secondary adrenal insufficiency, however, aldosterone is still produced, as its production is stimulated by other hormonal regulatory systems. The pituitary hormone which triggers cortisol production is called ACTH; it is responsible for the extra pigmentation found in primary Addisons. People with secondary adrenal failure do not experience the extra pigmentation found in primary Addisons, because their ACTH levels are declining. Long term use of high doses of steroid drugs to treat other illnesses (for example highdose prednisone for bowel disease or asthma) can also cause temporary or permanent loss of adrenal function. This is often referred to as secondary adrenal suppression. Until the development of steroid medication in the late 1940s, the outcome of adrenal disease was invariably fatal. With the development of modern steroid medications, individuals with Addisons disease can expect to have a fairly normal life span, provided they manage their daily medication sensibly. People with Addisons must always be aware of their own health and ready to increase their dosage if they get sick or are seriously injured. What Causes an Addisonian Crisis? The underlying cause of Addisonian crisisthe lack of cortisolis caused by damage to the adrenal glands. The adrenal glands sit above the kidneys. If your adrenal glands do not produce glucocorticoid hormones like cortisol, it compromises the bodys ability to develop effective immune responses. Stress can overwhelm someone who doesnt have the necessary adrenal hormones. Med ical experts believe that traumatic events like a car accident may trigger an Addisonian crisis. Even the flu or a stomach virus can stress out the body.

Who Is at Risk for an Addisonian Crisis? Those most at risk for Addisonian crisis are: individuals suffering from Addisons disease people who have damage to the pituitary gland, where adrenal insufficiency may be a result patients being treated for any kind of adrenal insufficiency and who do not take their medication people who are experiencing some kinds of physical trauma and stress surgical patients individuals who are experiencing dehydration

Those most at risk for Addisonian crisis are: individuals suffering from Addisons disease people who have damage to the pituitary gland, where adrenal insufficiency may be a result patients being treated for any kind of adrenal insufficiency and who do not take their medication people who are experiencing some kinds of physical trauma and stress surgical patients

individuals who are experiencing dehydration

Symptoms of Addisonian Crisis If you are experiencing an Addisonian crisis, you may experience a range of symptoms. Some symptoms resemble those of other conditions. They are: nausea or abdominal pain vomiting fever joint pain loss of appetite dramatic changes in blood pressure weakness chills rashes of the skin an irregularly high heart rate Some patients may experience a craving for salt, for example. Others may feel fatigued, experience darkening of the skin, or have unintentional weight loss.Many of these symptoms can develop over time as part of Addisons disease.

When were stressed out, our adrenal glands produce a hormone called cortisol. Cortisol helps our bodies respond effectively to stress. It also plays a role in bone health, immune response, and the metabolism of food. People who have Addisons disease dont make enough cortisol or aldosterone. Low levels of cortisol may cause weakness, fatgue and low blood pressure. Aldosterone regulates sodium and potassium levels. When levels of cortisol fall rapidly, you develop Addisonian crisis. Addisonian crisis, also called acute adrenal insufficiency, is a serious emergency condition. Addisonian crisis can be a life-threatening condition. The patient can go into shock. An Addisonian crisis can be extremely dangerous if cortisol levels are not replaced. What Causes an Addisonian Crisis? The underlying cause of Addisonian crisisthe lack of cortisolis caused by damage to the adrenal glands. The adrenal glands sit above the kidneys. If your adrenal glands do not produce glucocorticoid hormones like cortisol, it compromises the bodys ability to develop effective immune responses. Stress can overwhelm someone who doesnt have the necessary adrenal hormones. Medical experts believe that tr aumatic events like a car accident may trigger an Addisonian crisis. Even the flu or a stomach virus can stress out the body.

Who Is at Risk for an Addisonian Crisis? Those most at risk for Addisonian crisis are: individuals suffering from Addisons disease people who have damage to the pituitary gland, where adrenal insufficiency may be a result patients being treated for any kind of adrenal insufficiency and who do not take their medication people who are experiencing some kinds of physical trauma and stress surgical patients individuals who are experiencing dehydration

Symptoms of Addisonian Crisis If you are experiencing an Addisonian crisis, you may experience a range of symptoms. Some symptoms resemble those of other conditions. They are: nausea or abdominal pain vomiting fever joint pain loss of appetite dramatic changes in blood pressure weakness chills rashes of the skin an irregularly high heart rate Some patients may experience a craving for salt, for example. Others may feel fatigued, experience darkening of the skin, or have unintentional weight loss.Many of these symptoms can develop over time as part of Addisons disease.

Diagnosing Addisonian Crisis Your doctor may use various blood tests to determine if your adrenal hormone levels are normal. These might include: an ACTH or Cosyntropin (Cortrosyn) Stimulation Test, where a doctor will assess your cortisol levels relative to an ACTH injection a fasting blood sugar test a serum potassium or serum sodium test a simple cortisol test

Your doctor may use various blood tests to determine if your adrenal hormone levels are normal. These might include: an ACTH or Cosyntropin (Cortrosyn) Stimulation Test, where a doctor will assess your cortisol levels relative to an ACTH injection a fasting blood sugar test a serum potassium or serum sodium test a simple cortisol test

How Do You Treat Addisonian Crisis? Medications People who are experiencing an Addisonian crisis typically get an immediate injection of hydrocortisone. If you visit an emergency room or doctors office, you may be given an injection through a vein, or in your muscles. Home Care If you have already been diagnosed with Addisons disease, you may have a kit that includes a hydrocortisone injection available. Treatment for Severe Addisonian Crisis After an Addisonian crisis, your doctor may also recommend going to a hospital for ongo ing evaluation. Youll want to make sure that your adrenal insufficiency has been effectively treated.

Cushing syndrome
Cushing syndrome occurs when your body is exposed to high levels of the hormone cortisol for a long time. The most common cause of Cushing syndrome, sometimes called hypercortisolism, is the use of oral corticosteroid medication. The condition can also occur when your body makes too much cortisol. Too much cortisol can produce some of the hallmark signs of Cushing syndrome a fatty hump between your shoulders, a rounded face, and pink or purple stretch marks on your skin. Cushing syndrome can also result in high blood pressure, bone loss and, on occasion, diabetes. Treatments for Cushing syndrome can return your body's cortisol production to normal and noticeably improve your symptoms. The earlier treatment begins, the better your chances for recovery.

SYPMTOMS The signs and symptoms of Cushing syndrome vary. Common signs and symptoms involve progressive obesity and skin changes, such as: Weight gain and fatty tissue deposits, particularly around the midsection and upper back, in the face (moon face), and between the shoulders (buffalo hump) Pink or purple stretch marks (striae) on the skin of the abdomen, thighs, breasts and arms Thinning, fragile skin that bruises easily

Slow healing of cuts, insect bites and infections Acne

Women with Cushing syndrome may experience: Thicker or more visible body and facial hair (hirsutism) Irregular or absent menstrual periods

Men with Cushing syndrome may experience: Decreased libido Decreased fertility Erectile dysfunction

Other signs and symptoms include: Fatigue Muscle weakness Depression, anxiety and irritability Loss of emotional control Cognitive difficulties New or worsened high blood pressure Glucose intolerance that may lead to diabetes Headache Bone loss, leading to fractures over time

When to see a doctor If you're taking corticosteroid medications to treat a condition, such as asthma, arthritis or inflammatory bowel disease, and experience signs and symptoms that may indicate Cushing syndrome, see your doctor for an evaluation. Even if you're not using these drugs and you have symptoms that suggest the possible presence of Cushing syndrome, contact your doctor.

Causes Cushing syndrome results from excess levels of the hormone cortisol in your body. Your endocrine system consists of glands that produce hormones that regulate processes throughout your body. These glands include the adrenal glands, pituitary gland, thyroid gland, parathyroid glands, pancreas, ovaries (in females) and testicles (in men). Your adrenal glands produce a number of hormones, including cortisol. Cortisol plays a variety of roles in your body. For example, cortisol helps regulate your blood pressure and keeps your cardiovascular system functioning normally. It also helps your body respond to stress and regulates the way you convert (metabolize) proteins, carbohydrates and fats in your diet into usable energy. However, when the level of cortisol is too high in your body, you may develop Cushing syndrome. The role of corticosteroids Cushing syndrome can develop from a cause that originates outside of your body (exogenous Cushing syndrome). Taking corticosteroid medications in high doses over an extended period of time may result in Cushing syndrome. These medications, such as prednisone, have the same effects as does the cortisol produced by your body. Your doctor may prescribe corticosteroids to treat inflammatory diseases, such as rheumatoid arthritis, lupus and asthma, or to prevent your body from rejecting a transplanted organ. Because the doses required to treat these conditions are often higher than the amount of cortisol your body normally needs each day, the effects of excess cortisol can occur.

People can also develop Cushing syndrome from injectable corticosteroids for example, repeated injections for joint pain, bursitis and back pain. While certain inhaled steroid medicines (taken for asthma) and steroid skin creams (used for skin disorders such as eczema) are in the same general category of drugs, they're less likely to cause Cushing syndrome, but may in some individuals especially if taken in high doses. Your body's own overproduction The condition may also be due to your body's own overproduction of cortisol (endogenous Cushing syndrome). This may occur from excess production by one or both adrenal glands, or overproduction of the adrenocorticotropic hormone (ACTH), which normally regulates cortisol production. In these cases, Cushing syndrome may be related to: A pituitary gland tumor (pituitary adenoma). A noncancerous (benign) tumor of the pituitary gland, located at the base of the brain, secretes an excess amount of ACTH, which in turn stimulates the adrenal glands to make more cortisol. When this form of the syndrome develops, it's called Cushing disease. It occurs much more often in women and is the most common form of endogenous Cushing syndrome. An ectopic ACTH-secreting tumor. Rarely, when a tumor develops in an organ that normally does not produce ACTH, the tumor will begin to secrete this hormone in excess, resulting in Cushing syndrome. These tumors, which can be noncancerous (benign) or cancerous (malignant), are usually found in the lungs, pancreas, thyroid or thymus gland. A primary adrenal gland disease. In some people, the cause of Cushing syndrome is excess cortisol secretion that doesn't depend on stimulation from ACTH and is associated with disorders of the adrenal glands. The most common of these disorders is a noncancerous tumor of the adrenal cortex, called an adrenal adenoma. Cancerous tumors of the adrenal cortex (adrenocortical carcinomas) are rare, but they can cause Cushing syndrome as well. Occasionally, benign, nodular enlargement of both adrenal glands can result in Cushing syndrome. Familial Cushing syndrome. Rarely, people inherit a tendency to develop tumors on one or more of their endocrine glands, affecting cortisol levels and causing Cushing syndrome.

Complications If you don't receive prompt treatment for Cushing syndrome, other complications may occur, such as: Bone loss (osteoporosis), which can result in unusual bone fractures, such as rib fractures and fractures of the bones in the feet High blood pressure (hypertension) Diabetes Frequent or unusual infections Loss of muscle mass and strength

When the cause of Cushing syndrome is a pituitary tumor (Cushing disease), it can sometimes lead to other problems, such as interfering with the production of other hormones controlled by the pituitary. TEST AND DIAGNOSIS Cushing syndrome can be difficult to diagnose, particularly endogenous Cushing syndrome, because other conditions share the same signs and symptoms. Your doctor will conduct a physical exam, looking for signs of Cushing syndrome. He or she may suspect Cushing syndrome if you have signs such as rounding of the face (moon face), a pad of fatty tissue between the shoulders and neck (buffalo hump), and thin skin with bruises and stretch marks.

If you've been taking a corticosteroid medication for a long time, your doctor may suspect that you've developed Cushing syndrome as a result of this medication. If you haven't been using a corticosteroid medication, these diagnostic tests may help pinpoint the cause: Urine and blood tests. These tests measure hormone levels in your urine and blood and show whether your body is producing excessive cortisol. For the urine test, you may be asked to collect your urine over a 24-hour period. Both the urine and blood samples will be sent to a laboratory to be analyzed for cortisol levels. Your doctor might also recommend other specialized tests that evaluate the blood and urine to help determine if Cushing syndrome is present and to help identify the underlying source of any excess production. These tests often involve measuring cortisol levels before and after stimulation or suppression with other hormone medications. Saliva test. Cortisol levels normally rise and fall throughout the day. In people without Cushing syndrome, levels of cortisol drop significantly in the evening. By analyzing cortisol levels from a small sample of saliva collected late at night, doctors can see if cortisol levels are too high, suggesting a diagnosis of Cushing syndrome. Imaging tests. Computerized tomography scans or magnetic resonance imaging scans can provide images of your pituitary and adrenal glands to detect abnormalities, such as tumors. As these tests help your doctor diagnose Cushing syndrome, they may also rule out medical conditions with similar signs and symptoms. For example, polycystic ovary syndrome a hormone disorder in women with enlarged ovaries shares some of the same signs and symptoms as Cushing has, such as excessive hair growth and irregular menstrual periods. Depression, eating disorders and alcoholism also can partially mimic Cushing syndrome. TREATMENTS AND DRUGS Treatments for Cushing syndrome are designed to lower the high level of cortisol in your body. The best treatment for you depends on the cause of the syndrome. Treatment options include: Reducing corticosteroid use. If the cause of Cushing syndrome is long-term use of corticosteroid medications, your doctor may be able to keep your Cushing signs and symptoms under control by reducing the dosage of the drug over a period of time, while still adequately managing your asthma, arthritis or other condition. For many of these medical problems, your doctor can prescribe noncorticosteroid drugs, which will allow him or her to reduce the dosage or eliminate the use of corticosteroids altogether. Don't reduce the dose of corticosteroid drugs or stop taking them on your own. Do so only under your doctor's supervision. Abruptly discontinuing these medications could lead to deficient cortisol levels. Slowly tapering off corticosteroid drugs allows your body to resume normal cortisol production. Surgery. If the cause of Cushing syndrome is a tumor, your doctor may recommend complete surgical removal. Pituitary tumors are typically removed by a neurosurgeon, who may perform the procedure through your nose. If a tumor is present in the adrenal glands, lungs or pancreas, the surgeon can remove it through a standard operation or in some cases by using minimally invasive surgical techniques, with smaller incisions. After the operation, you'll need to take cortisol replacement medications to provide your body with the correct amount of cortisol. In most cases, you'll eventually experience a return of normal adrenal hormone production, and your doctor can taper off the replacement drugs. However, this process can take up to a year or longer. In some instances, people with Cushing syndrome never experience a resumption of normal adrenal function; they then need lifelong replacement therapy. Radiation therapy. If the surgeon can't totally remove a pituitary tumor, he or she will usually prescribe radiation therapy to be used in conjunction with the operation. Additionally, radiation may be used for people who aren't suitable candidates for surgery.

Radiation can be given in small doses over a six-week period or by a technique called stereotactic radiosurgery (Gamma Knife surgery). In the latter procedure, administered as a single treatment, a large dose of radiation is delivered to the tumor, and the radiation exposure to surrounding tissues is minimized. Medications. Medications can be used to control cortisol production when surgery and radiation don't work. Medications may also be used before surgery in people who have become very sick with Cushing syndrome. Doctors recommend drug therapy before surgery to improve signs and symptoms and minimize surgical risk. Medications to control excessive production of cortisol include ketoconazole (Nizoral), mitotane (Lysodren) and metyrapone (Metopirone). The Food and Drug Administration has also approved the use of mifepristone (Korlym) for people with Cushing syndrome who have type 2 diabetes or glucose intolerance. Mifepristone does not decrease cortisol production, but it blocks the effect of cortisol on your tissues. In some cases, the tumor or its treatment will cause other hormones produced by the pituitary or adrenal gland to become deficient and your doctor will recommend hormone replacement medications. If none of these treatment options is effective, your doctor may recommend surgical removal of your adrenal glands (bilateral adrenalectomy). This procedure will cure excess production of cortisol. However, your ACTH levels will remain high, possibly causing excess pigmentation of your skin.

NURSING INTERVENTION 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Consult a dietician to plan a high in protein and potassium but low in calories, carbohydrates, and sodium. Use protective measures to reduce the risk of infection. Schedule activites around the patients rest periods to avoid fatigue. Institute safety precaustions to minimize the risk of injury from the falls. Help the client to walk, to avoid bumps and bruises. Help the bedridden patient to turn and reposition herself every 2 hours. Use extreme caution when moving the patient to minimize trauma and bone stress. Provide frequent skin care, especially over bony prominences. Provide support with pillows and a convoluted foam mattress. Encourage the patient to verbalize her feelings about the body image changes and sexual dysfunction. Prepare the patient for surgery if indicated. Nursing Interventions 1. Maintain muscle tone Provide ROM exercises Assist with ambulation Prevent accidents or falls and provide adequate rest Protect client from exposure to infection Maintain skin integrity Provide meticulous skin care Prevent tearing of skin: use paper tape if necessary Minimize stress in the environment Monitor vital signs; observe for hypertension, edema Measure I&O and daily weights Provide diet low in calories, sodium and high in protein, potassium, calcium, and vitamin D. Monitor urine for glucose and acetone; administer insulin if ordered

10.Provide psychologic support and acceptance 11.Prepare client for hypophysectomy or radiation if condition is caused by a pituitary tumor 12.Prepare client for an adrenal tumor or hyperplasia 13.Provide client teaching and discharge planning concerning Diet modifications Importance of adequate rest Need to avoid stress and infection Change in medication regimen (alternate day therapy or reduced dosage) if cause of the condition is prolonged corticosteroid therapy

CONNS DISEASE What is a Conns syndrome? Conns syndrome is a condition associated with the development of high blood pressure and low potassium levels in the blood. In patient with a recent diagnosis of hypertension ( high blood pressure), the findings of a low potassium level should lead to a search for this disease since it is a curable cause for high blood pressure. Patients with Conns syndrome have a tumor in their adrenal cortex (the outer part of the adrenal gland) that produces an exc essive amount of a hormone aldosterone. Aldosterone is a hormone that is normally involved in regulating the amount of salt in the body. In patients who have overproduction of this hormone, excessive amount of salt is retained in their body and potassium is lost, leading to high blood pressure and low potassium levels. Conn's syndrome is a disease of the adrenal glands involving excess production of a hormone, called aldosterone. Another name for the condition is primary hyperaldosteronism. Conn's syndrome is important because it is a potentially curable cause of high blood pressure (hypertension). Some studies suggest that Conn's syndrome is rare (one new case in a million people each year). However, when detailed investigations have been performed in patients with hypertension (high blood pressure), up to 15 per cent may have this condition.

What is the cause for Conns syndrome? In the majority of patients a small tumor is found in the adrenal cortex (the outer part of the adrenal gland). Excess production of aldosterone by the tumor leads to the development of Conns syndrome with high blood pressure and low potassium levels. Not a ll patients with a Conns syndrome will have a tumor. In a sm all group of patients abnormal function of the adrenal cortex from a condition called adrenal hyperplasia may give rise to the Conns syndrome. Surgical removal of the tumor can lead to cure of the high blood pressure and low potassium levels in patients w ith Conns syndrome. In patients who have abnormal function of the adrenal gland due to adrenal hyperplasia, surgery is usually not recommended. Why or how do I get Conn's syndrome and what is its course? The excess secretion of the hormone aldosterone into the blood is from an abnormal adrenal gland or glands. Two types of abnormality are seen: a benign tumour of one adrenal, called an adenoma or a general enlargement of both adrenals, called hyperplasia. The underlying reasons for the development of an adenoma or hyperplasia are not known.

What are the symptoms? High blood pressure (hypertension) is the main, and often the only, symptom. Other symptoms may occur because high aldosterone levels in the blood act on the kidney to increase the loss of the mineral potassium in the urine. This in turn may lead to a fall in blood potassium, resulting in tiredness, muscle weakness and passing of large volumes of urine (polyuria), especially at night (nocturia). However, these symptoms are also found in many other conditions (for example, diabetes mellitus or hypercalcaemia) and do not, by themselves, establish a diagnosis of Conn's syndrome. Also, many patients with proven Conn's syndrome do not have a low blood potassium level.

How are adrenal tumors diagnosed? A thin section CT scan of the adrenal glands can diagnose between 75% and 95% of the adrenal tumors that causes a Conns syndrome. Very small tumors less than 7 mm may be missed on CT scanning. Where this diagnosis is suspected and a tumor is not seen on CT scan, a specialized test available at USC called differential venous sampling for aldosterone may provide the diagnosis for this disorder. In this test a radiologist inserts a small catheter into the adrenal vein (the blood vessel that transports blood away from the adrenal glands) to measure for the amount of the hormone aldosterone in the blood on the two sides of the body. In patients who have a tumor, the side where the tumor is located will show excessive amounts of aldosterone on the tested blood. How is Conns syndrome treated? Surgical removal of the adrenal gland where the tumor is located is the treatment of choice. This operation called an adrenalectomy will lead to cure of the blood pressure and the low potassium problems in patients with Conns syndrome. After removal of the tumor blood pressure levels usually return to normal in most patients. Occasionally in some patients that have had a tumor for long time, persistent elevation in their blood pressure may continue after the surgery due to preexisting damage to their blood vessels.

Laparoscopic adrenalectomy is a treatment of choice for removing the adrenal gland in patients with a Conns syndrome. Since these are benign small tumors an open surgical operation is not indicated due to the excessive amount of pain, discomfort and the prolonged healing periods required for the open operation compared to the laparoscopic operation.