Syndrome: excessive activation of glucocorticoid receptors.
Disease: excessive ACTH due to pituitary adenoma.
Classification:
 ACTH-dependent  pituitary adenoma, ectopic ACTH, iatrogenic.
 ACTH-independent  iatrogenic, adrenal adenoma/carcinoma.
 Pseudo-Cushing’s  EtOH excess, major depressive disorder, 1  obesity
Clinical features: hair thinning, hirsuitism, psychosis, acne, plethora, cataracts, mild exophthalmos, moon face, peptic ulcers, vertebral #, hypertension, hyperglycaemia, central adiposity, menstrual disturbance, striae, decreased skin thickness, osteoporosis, proximal myopathy,  infections, poor wound healing, bruising, impaired immune response.
Investigations:
 Bedside  cap glucose, BP.
 Bloods  dexamethasone suppression test, CRH test, serum cortisol.
 Imaging  MRI brain, CXR, CT AP/adrenals.
 Others  inferior venous petrosal sampling, urinary free cortisol.
Management:
 Conservative  patient education, reduce oral steroid therapy if possible.
 Medical  ketoconazole/metyrapone (  steroid synthesis).
 Surgical  trans-sphenoidal resection of pituitary.
Definition: a syndrome resulting from inadequate secretion of corticosteroid hormones from progressive destruction of the adrenal cortex.
Causes: “ADDISON” – Autoimmune, Degenerative, Drugs, Infective, Secondary,
Other, Neoplasia.
Clinical features: bronze pigmentation of skin, tiredness, hypoglycaemia, postural hypotension, changes in distribution of body hair, weight loss, GI disturbance. Associated with type 1 diabetes, pernicious anaemia, autoimmune thyroid disease and vitiligo.
Investigations:
 Bedside  lying/standing BP, capillary glucose.
 Bloods  U&Es, synacthen test, plasma renin, aldosterone, HIV test.
 Imaging  AXR, CT/MRI adrenals.
Management:
 Glucocorticoid replacement – hydrocortisone BD.
 Mineralocorticoid replacement – fludrocortisone OD.
 Addisonian crisis (shock, hypotension, abdo pain, N&V,  Na + /  K + ) –
ABCDE, correct volume depletion, replace glucocorticoids, correct metabolic abnormalities, treat underlying cause.
Definition: a condition caused by excessive growth hormone secretion.

Causes: most commonly, pituitary adenoma.
Clinical features: headache, skull growth (prominent supraorbital ridge with large frontal sinuses), enlargement of lips, nose and tongue, prognathism, cardiomyopathy, increased sweating, thickened skin, hepatomegaly, type 2 diabetes, enlargement of hands, carpal tunnel syndrome, myopathy, enlargement of feet, visual field changes, diplopia.
Investigations:
 Bedside  collateral hx, serial photographs, BP, ECG.
 Bloods  serum GH, OGTT, serum IGF-1.
 Imaging  CT/MRI brain, echo.
 Other  colonoscopy.
Management:
 Conservative  patient education.
 Medical (second line)  somatostatin analogues (octreotide, lanreotide), dopamine agonists, GH receptor anatagonists (pegvisomant).
 Surgery (first line)  trans-sphenoidal debulking of tumour.
 Radiotherapy  if acromegaly persists after surgery.