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What is Cushing Syndrome?

Question:

Discuss about the Trends in Endocrinology and Metabolism.

Cushing syndrome is caused by excessive production or exposure to the hormone cortisol. Elaborating more on the hormone cortisol, it can be mentioned that this hormone is produced by the adrenal cortex of the adrenal glands in the human body and is responsible for many key physiological function of the body. This hormone plays fundamental roles in maintaining and regulating the functionality of the cardiovascular system and helps in the task of maintaining the blood pressure of the body. On a more elaborative note, it has to be mentioned that there is an intricate hormonal signalling framework invested in the process of hypercortisolism. The paraventricular nucleus present in the hypothalamus contains neuroendocrine neurons that secrete the corticotrophin releasing hormone or CRH (Brown et al., 2017). This hormone in turn controsl the secretin of adenocorticotropin hormone or ACTH from the anterior lobe of the pituitary glands. Now the feedback loop of both of the hormone affects the adrenal cortex and in turn affects the cortisol hormone. Now Cushing’s syndrome is characterized by the overproduction of cortisol hormone and there can be a few conditions that can lead to his phenomenon. A tumor is the most likely cause, either in the pituitary gland, adrenal gland, or somewhere else in case of ectopic Cushing syndrome. However another very common concern for overproduction of the hormone cortisol is the prolonged usage of the corticosteroids. In this case the patient had been suffering from rheumatoid arthritis from the age of 15 year, and had to undergo a prolonged period of corticosteroid therapy, hence for the patient, this the most plausible cause (Crespo Martín et al., 2016). Considering the incidence rate of the disease in Australia, the statistics reveal that 1-2 people per 100000 individuals are suffering from this disease. The prevalence of this disease in Australia is close to 40 per 100000 people.

Considering the risk factors for this disease, obesity, type 2 diabetes, rheumatoid arthritis, corticosteroid therapy and tumors can be the most plausible ones. However, in this case the age and gender can also be important risk factors for this disease, as it is more commonly found in women rather than in men. The patient has been suffering from gastrointestinal bleeding, muscle weakness and fatigue due to this disease, it can impact her social and personal life. It might restrict her from participating in the day to day activities that she is usually accustomed with. Another very important impact of this disease is the localized obesity which can contribute to altered body image which can be a significant psychological burden on the patient and can impose social withdrawal and loss of self worth (De Freitas Luzia, de Goes Victor & de Fátima Lucena, 2014). And the patient family might suffer emotionally and economically while attending to and watching their loved one suffer.

Causes of Cushing Syndrome

There are various signs and symptoms that are associated with the Cushing’s syndrome and each of the signs contributes to the deterioration of the health and wellbeing of the patient. Among all different kinds of signs and symptoms, 5 key ones are,

  • One of most conspicuously significant signs of the Cushing’s syndrome can be the moon face. It has to be understood that the hormonal imbalance caused by this particular disease in the body results into abnormal and localized fat deposition. The rounding of the face is due to the fat deposition around the face facilitated by increased fat metabolism due to cortisol imbalance and prolonged consumption of prednisone (Ejaz et al., 2011).
  • The second sign or symptom that can be mentioned in this context is the abnormal weigh gain and abdominal obesity. It has to be mentioned that the imbalance in the feedback loop between the CRH, ACTH, and the increased concentration of the cortisol hormone often results into increased fat accumulation in the particular locations of the body, especially in the abdominal section resulting into a conspicuous abdominal obesity and can even lead to a fatty hump between the shoulders, which had been also reported in Maureen (Feelders et al., 2010).
  • Another very important and signature sign or symptom for this disease is the onset of hypertension. The mechanism of hypertension or high blood pressure in the Cushing’s syndrome is facilitated by the hypersecretion of glucocorticoids. And along with that it has to be mentioned that increased cortisol levels in the body even leads to high mineralocorticoid secretion. Both of this cumulatively impact on cardiovascular regulatin and in turn cardiac output, hence resulting into hypertension. The impact of obesity and diabetes which is often associated with this disease and as is in this case as well, might also contribute to the increase in the blood pressure (Guaraldi & Salvatori, 2012).
  • Lastly fatigue and muscle weakness is the also a key sign or symptom of the disease is the muscle and bone weakness that is frequently observed in the patients. It has to be understood that the HPA hub or the hypothalamus-adrenal conjuncture helps to control the stress response and induction in the body. As he increased level of cortisol disrupts the equilibrium of the HPA hub functions, impacts the mucular dystrophy and causes muscle fatigue (Fleseriu & Petersenn, 2015).

The first class of drugs that can be given to the patient includes the steroid inhibitors like  mifepristone. It has to be mentioned this is an abortifacient drug that is used for helping the patients suffering from Cushing’s syndrome as a critical antagonist of steroidal medication. According to the research it is the second most favoured line of drugs in case of the treating or managing the symptoms of the Cushing syndrome. Exploring the mechanism of action of this class of drug it can be mentioned that it acts as the perfect antagonist to the glucocorticoids by the means of inhibiting the progestin receptors. This is the most favoured medication for patients who have diabetes type 2 along with Cushing syndrome and helps in regulating the ACTH levels in body as well. Along with that, this medication has been proved to act on the hypertension symptoms of the body as well making it the best choice for Maureen (Mazziotti, Gazzaruso & Giustina, 2011).

The second line of drugs that the patient will require will be for managing the imbalance of cortisol in the body, hence the first class of drugs that can be given to the patient is the cortisol lowering medication like the ketoconazole or Nizoral. It has to be mentioned in this context that ketoconazole is nothing but a synthetic imidazole that is the most favourable and frequently used medication for this disease. It has to be mentioned in this context that this is a potent antifungal antibiotic which acts exceptionally well in balancing the cortisol levels in the body. According to the research ketoconazole helps in the process of steroidogenesis and controls the production or exposure of the patient to corticosteroids and its impact that the overexposure will have on the pathophysiology of the patient. Elaborating on the pathophysiology of the mechanism of action that this medication, it can be mentioned that this acts like an inhibitor of the key enzymes and cytochromes in the pathway of production of the steroid hormones (Nieman, 2015). However, there are various side effects like the nausea, gastrointestinal bleeding, confusion, depression and even liver damage hence the dosage calculation needs to be very precise.

Symptoms of Cushing Syndrome

The case study represents the condition of a young patient named Maureen Smith, who had been represented in the heath care facility with gastrointestinal bleeding, abdominal pain and fatigue. The past medical history of the patient is presenting the diagnosis of rheumatoid arthritis diagnosed at 15 years of age and type 2 diabetes. Based on the assessment data and the blood test results, it had been discovered that the most plausible diagnosis is Cushing syndrome. It has to be mentioned that Cushing syndrome is a common disorder caused by the overproduction of the hormone cortisol in the body (Pivonello et al., 2016). The medical term for this disease is hypercortisolism and it is a very common condition and can be facilitated by the fact overexposure to the hormone cortisol in the body. In this case the care plan for the patient will require to be completely based on the three key symptoms that the patient has been presented with and will also focus on the related psychosocial concerns that the patient might face in the future.

Care priority

Nursing outcome

Intervention

Rationale

Gastrointestinal bleeding and abdominal pain

The patient will be relieved of the pain and the bleeding will cease completely

The nursing profession will monitor the vital signs of the patient and will perform haemoglobin count check.

Administration of diuretics and hypertensive medication like pantaprazole

Move the patient into recovery position to ensure that the patient is relaxed and comfortable

Vital signs will analyse the condition of the patient and haemoglobin count will be indicative of the accurate blood loss.

The mediction will help reduce the blood pressure and will help in managing the blood loss

The recovery position will calm the patient (Raff, H, & Carroll, 2015).

Muscle weakness and fatigue

The patient will be relieved from the risk of injury due to weakness and fatigue

Assessment of skin integrity to check for any skin redness, bumps or bleeding.

Administering a fibre and antioxidant rich diet to help the patient regain energy and health (Tiryakioglu et al., 2010).

High cortisol levels have detrimental impact on the skin integrity.

 A facultative energy inducing diet will help the patient overcome the weakness and fatigue.

Risk for infection and pain

The patient will be relieved from the risk of infection or any pain.

Through assessment of the patient to check for any visible signs of infection

Rapid and prompt diagnosis of the symptoms will be helpful to provide instant intervention.

Altered body image and localised obesity.

The patient will be accepting of the changes in her body image and will be relieved from any depression or loss of self worth.

Engage the patient with positive therapeutic interaction about self worth and body image.

Help her with personal grooming and CBT intervention to enhance her coping strategy.

The engagement wil help her with her self imposed social isolation and will improve her perceptions of body image (Tritos, Biller & Swearingen, 2011).

The grooming and psychotherapy will help in overcoming any depression.

References:

Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2017). Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

Crespo Martín, I., Youdale, S. W., Valassi, E., & Resmini, E. (2016). Neuropsychological evaluation of patients with acromegaly and Cushing's syndrome: Long-term effects.

De Freitas Luzia, M., de Goes Victor, M. A., & de Fátima Lucena, A. (2014). Nursing Diagnosis Risk for falls: prevalence and clinical profile of hospitalized patients. Revista Latino-Americana de Enfermagem, 22(2), 262.

Ejaz, S., Vassilopoulou?Sellin, R., Busaidy, N. L., Hu, M. I., Waguespack, S. G., Jimenez, C., ... & Habra, M. A. (2011). Cushing syndrome secondary to ectopic adrenocorticotropic hormone secretion. Cancer, 117(19), 4381-4389.

Feelders, R. A., de Bruin, C., Pereira, A. M., Romijn, J. A., Netea-Maier, R. T., Hermus, A. R., ... & de Herder, W. W. (2010). Pasireotide alone or with cabergoline and ketoconazole in Cushing's disease. New England Journal of Medicine, 362(19), 1846-1848.

Fleseriu, M. (2015). Medical treatment of Cushing disease: new targets, new hope. Endocrinology and Metabolism Clinics, 44(1), 51-70.

Fleseriu, M., & Petersenn, S. (2015). Medical therapy for Cushing’s disease: adrenal steroidogenesis inhibitors and glucocorticoid receptor blockers. Pituitary, 18(2), 245-252.

Guaraldi, F., & Salvatori, R. (2012). Cushing syndrome: maybe not so uncommon of an endocrine disease. The Journal of the American Board of Family Medicine, 25(2), 199-208.

Mazziotti, G., Gazzaruso, C., & Giustina, A. (2011). Diabetes in Cushing syndrome: basic and clinical aspects. Trends in Endocrinology & Metabolism, 22(12), 499-506.

Nieman, L. K. (2015). Cushing's syndrome: update on signs, symptoms and biochemical screening. European journal of endocrinology, 173(4), M33-M38.

Pivonello, R., Isidori, A. M., De Martino, M. C., Newell-Price, J., Biller, B. M., & Colao, A. (2016). Complications of Cushing's syndrome: state of the art. The Lancet Diabetes & Endocrinology, 4(7), 611-629.

Raff, H., & Carroll, T. (2015). Cushing's syndrome: from physiological principles to diagnosis and clinical care. The Journal of physiology, 593(3), 493-506.

Tiryakioglu, O., Ugurlu, S., Yalin, S., Yirmibescik, S., Caglar, E., Yetkin, D. O., & Kadioglu, P. (2010). Screening for Cushing's syndrome in obese patients. Clinics, 65(1), 9-13.

Tritos, N. A., Biller, B. M., & Swearingen, B. (2011). Management of Cushing disease. Nature Reviews Endocrinology, 7(5), 279.

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