Management of the Patient with Suspected Cushing's Syndrome - Flowchart
Management of the Patient with Suspected Cushing's Syndrome - Flowchart
«Flowchart»

ALGORITHM FOR MANAGEMENT OF THE PATIENT WITH SUSPECTED CUSHING’S SYNDROME

ALGORITHM FOR MANAGEMENT OF THE PATIENT WITH SUSPECTED CUSHING’S SYNDROME

ALGORITHM FOR MANAGEMENT OF THE PATIENT WITH SUSPECTED CUSHING’S SYNDROME

ALGORITHM FOR MANAGEMENT OF THE PATIENT WITH SUSPECTED CUSHING’S SYNDROME LGORITHM FOR ANAGEMENT OF THE ATIENT WITH USPECTED USHING’S YNDROME

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Clinical suspicion of Cushing’s
(Central adiposity, proximal myopathy, striae, amenorrhea, hirsutism, impaired glucose tolerance, diastolic hypertension, and osteoporosis)

Clinical suspicion of Cushing’s
(Central adiposity, proximal myopathy, striae, amenorrhea, hirsutism, impaired glucose tolerance, diastolic hypertension, and osteoporosis)

Clinical suspicion of Cushing’s
(Central adiposity, proximal myopathy, striae, amenorrhea, hirsutism, impaired glucose tolerance, diastolic hypertension, and osteoporosis)

Clinical suspicion of Cushing’s

Screening/confirmation of diagnosis


24-h urinary free corrtisol excretion increased above normal (3x)
Dexamethasone overnight test (Plasma cortisol >50 nmol/L at 8–9 AM after 1 mg dexamethasone at 11 PM)
Midnight plasma cortisol >130 nmol/L (or midnight salivary cortisol >5 nmol/L)

If further confirmation needed/desired:


Low dose DEX test (Plasma cortisol >50 nmol/L after 0.5 mg dexamethasone q6h for 2 days)

Screening/confirmation of diagnosis


24-h urinary free corrtisol excretion increased above normal (3x)
Dexamethasone overnight test (Plasma cortisol >50 nmol/L at 8–9 AM after 1 mg dexamethasone at 11 PM)
Midnight plasma cortisol >130 nmol/L (or midnight salivary cortisol >5 nmol/L)

If further confirmation needed/desired:


Low dose DEX test (Plasma cortisol >50 nmol/L after 0.5 mg dexamethasone q6h for 2 days)

Screening/confirmation of diagnosis

Screening/confirmation of diagnosis


24-h urinary free corrtisol excretion increased above normal (3x)
Dexamethasone overnight test (Plasma cortisol >50 nmol/L at 8–9 AM after 1 mg dexamethasone at 11 PM)
Midnight plasma cortisol >130 nmol/L (or midnight salivary cortisol >5 nmol/L)


24-h urinary free corrtisol excretion increased above normal (3x)
Dexamethasone overnight test (Plasma cortisol >50 nmol/L at 8–9 AM after 1 mg dexamethasone at 11 PM)
Midnight plasma cortisol >130 nmol/L (or midnight salivary cortisol >5 nmol/L)

If further confirmation needed/desired:

If further confirmation needed/desired: If further confirmation needed/desired:


Low dose DEX test (Plasma cortisol >50 nmol/L after 0.5 mg dexamethasone q6h for 2 days)


Low dose DEX test (Plasma cortisol >50 nmol/L after 0.5 mg dexamethasone q6h for 2 days)

Positive

Positive

Positive

Negative

Negative

Negative

ACTH-independent Cushing’s

ACTH-independent Cushing’s

ACTH-independent Cushing’s

ACTH-independent Cushing’s

ACTH-dependent Cushing’s

ACTH-dependent Cushing’s

ACTH-dependent Cushing’s

ACTH-dependent Cushing’s

Differential diagnosis 1: Plasma ACTH

Differential diagnosis 1: Plasma ACTH

Differential diagnosis 1: Plasma ACTH

Differential diagnosis 1:

ACTH normal or high >15 pg/ml

ACTH normal or high >15 pg/ml

ACTH normal or high >15 pg/ml

ACTH suppressed to <5 pg/ml

ACTH suppressed to <5 pg/ml

ACTH suppressed to <5 pg/ml

Cushing’s disease

Cushing’s disease

Cushing’s disease

Differential diagnosis 2


MRI pituitary
CRH test (ACTH increase >40% at 15–30 min + cortisol increase >20% at 45–60 min after CRH 100 µg IV)
High dose DEX test (Cortisol suppression >50% after q6h 2 mg DEX for 2 days)

Differential diagnosis 2


MRI pituitary
CRH test (ACTH increase >40% at 15–30 min + cortisol increase >20% at 45–60 min after CRH 100 µg IV)
High dose DEX test (Cortisol suppression >50% after q6h 2 mg DEX for 2 days)

Differential diagnosis 2

Differential diagnosis 2


MRI pituitary
CRH test (ACTH increase >40% at 15–30 min + cortisol increase >20% at 45–60 min after CRH 100 µg IV)
High dose DEX test (Cortisol suppression >50% after q6h 2 mg DEX for 2 days)


MRI pituitary
CRH test (ACTH increase >40% at 15–30 min + cortisol increase >20% at 45–60 min after CRH 100 µg IV)
High dose DEX test (Cortisol suppression >50% after q6h 2 mg DEX for 2 days)

CRH test and high dose DEX positive

CRH test and high dose DEX positive

CRH test and high dose DEX positive

Equivocal results

Equivocal results

Equivocal results

CRH test and high dose DEX negative

CRH test and high dose DEX negative

CRH test and high dose DEX negative

Ectopic ACTH production

Ectopic ACTH production

Ectopic ACTH production

Trans-sphenoidal pituitary surgery

Trans-sphenoidal pituitary surgery

Trans-sphenoidal pituitary surgery

Locate and remove ectopic ACTH source

Locate and remove ectopic ACTH source

Locate and remove ectopic ACTH source

Inferior petrosal sinus sampling (petrosal/peripheral ACTH ratio >2 at baseline, >3 at 2–5 min after CRH 100 µg i.v.)

Inferior petrosal sinus sampling (petrosal/peripheral ACTH ratio >2 at baseline, >3 at 2–5 min after CRH 100 µg i.v.)

Inferior petrosal sinus sampling (petrosal/peripheral ACTH ratio >2 at baseline, >3 at 2–5 min after CRH 100 µg i.v.)

Pos.

Pos.

Pos.

Neg.

Neg.

Neg.

Neg.

Neg.

Neg.

Bilateral adrenalectomy

Bilateral adrenalectomy

Bilateral adrenalectomy

Adrenal tumor workup

Adrenal tumor workup

Adrenal tumor workup

Unenhanced CT adrenals

Unenhanced CT adrenals

Unenhanced CT adrenals

Bilateral micronodular or macronodular adrenal hyperplasia

Bilateral micronodular or macronodular adrenal hyperplasia

Bilateral micronodular or macronodular adrenal hyperplasia

Unilateral adrenal mass

Unilateral adrenal mass

Unilateral adrenal mass

Unilateral adrenalectomy

Unilateral adrenalectomy

Unilateral adrenalectomy