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Endocrinology > Adrenal Gland
Pseudo-Cushing Syndrome
Article Last Updated: Jul 19, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: David M Klachko, MBBCh, Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Missouri
David M Klachko is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, Endocrine Society, Missouri State Medical Association, and Sigma Xi
Editors: Steven R Gambert, MD, Program Director, Physician-in-Chief, Professor, Department of Internal Medicine, Sinai Hospital, Johns Hopkins University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Yoram Shenker, MD, Chief of Endocrinology Section, VA Hospital of Madison, Interim Chief, Associate Professor, Department of Internal Medicine, Section of Endocrinology, Diabetes and Metabolism, University of Wisconsin at Madison; Mark Cooper, MD, Head, Vascular Division, Baker Medical Research Institute; Professor of Medicine, Monash University; George T Griffing, MD, Professor of Medicine, Director of General Internal Medicine, St Louis University
Author and Editor Disclosure
Synonyms and related keywords:
alcohol-induced pseudo-Cushing syndrome, adrenocortical secretion, Cushing disease, Cushing basophilism, corticotropin-releasing hormone, alcoholism, alcohol dependence
Background
In 1976, Smalls and associates described 3 alcoholic patients who had the physical and biochemical abnormalities of Cushing syndrome. Most of the abnormalities disappeared with 1-3 weeks of alcohol abstinence. About 30 cases have been reported. Similar abnormalities have also been described in patients with depression.
Pathophysiology
The mechanism remains unclear. Most evidence suggests central stimulation of a corticotropin-releasing hormone, either at the hypothalamic or suprahypothalamic level. Rats given 15% alcohol for 3 months showed increased numbers and increased secretory activity of corticotropin-producing cells.
Frequency
United States
In a study of 56 men in an alcohol detoxification unit, 18% had nonsuppressible serum cortisol levels. Many of these patients lacked the physical stigmata of Cushing syndrome, and some biochemical abnormalities resolved in a few days.
Mortality/Morbidity
- No deaths have been reported.
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- Persistence of abnormalities may lead to complications such as hypertension, glucose intolerance, diabetes mellitus, and osteoporosis.
Sex
Pseudo-Cushing syndrome occurs equally in men and women.
Age
Pseudo-Cushing syndrome occurs in people of any age, and it may occur in babies exposed to alcohol in breast milk.
History
The most important part of the history is the extent and duration of alcohol abuse. Similar factors should be assessed in regard to depression.
Physical
- Features of full-blown Cushing syndrome
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- Truncal obesity
- Plethoric moon face
- Buffalo hump
- Supraclavicular fat pads
- Hirsutism in women
- Thin skin with easy bruising and wide, purplish striae
- Hypertension
- Other patients have only a few symptoms or no physical evidence of glucocorticoid excess.
Causes
- The reason some alcoholic patients develop the problem and others do not is unknown.
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- Because biochemical abnormalities can resolve after a few days of alcohol abstinence, it may require long periods of excessive alcohol intake for the full syndrome to develop.
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- Attempts to find a genetic predisposition have been unsuccessful.
Cushing Syndrome
Depression
Other Problems to be Considered
Stress from severe illness
Lab Studies
- The 24-hour, urinary-free cortisol excretion level is moderately increased, usually not more than 2-3 times the reference range.
- Elevated levels of serum cortisol occur in the morning and evening.
- The morning serum cortisol level is not suppressed to less than 5 µg/dL by 1 mg dexamethasone administered at midnight.
- A midnight cortisol level of less than 7.5 µg/dL has 96% sensitivity and 100% specificity in differentiating pseudo-Cushing from true Cushing syndrome.
- Measurement of late-night salivary cortisol concentrations is increasingly used as a screening test in suspected Cushing syndrome
- Serum transaminase levels are usually elevated, suggesting alcohol-induced hepatitis.
- Blood alcohol level is useful only at the time of admission.
Medical Care
- Appropriate medical care depends on the reason the patient sought help.
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- Anticipate and prevent alcohol withdrawal syndrome. With abstinence from alcohol, biochemical abnormalities usually resolve within days or weeks.
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- Treat depression.
Consultations
Consult endocrinologists for patients with features of florid Cushing syndrome. Consult psychiatrists for treatment of depression or alcohol abuse.
Diet
Most patients with chronic alcoholism have varying degrees of malnutrition.
No specific medications are required except those for alcohol withdrawal or depression, which are beyond the scope of this article.
Further Inpatient Care
Treat patients for alcohol withdrawal or the presenting problem. Treat patients for depression.
Further Outpatient Care
- Refer patients for alcohol detoxification and rehabilitation.
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- Obtain an overnight dexamethasone suppression test or 24-hour urinary cortisol in 6-8 weeks.
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- Monitor patients until all test results are within reference ranges.
Transfer
- Patients usually require treatment in an alcohol detoxification and rehabilitation unit.
Complications
- Complications involve persistence of abnormalities, including the following:
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- Hypertension
- Glucose intolerance or diabetes mellitus
- Osteoporosis
Prognosis
- With abstinence from alcohol, all biochemical abnormalities return to reference ranges.
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- Relapse is frequent in patients with chronic alcoholism.
Patient Education
The physician should stress the deleterious effects of the disorder on health status and lifespan.
Medical/Legal Pitfalls
Acute withdrawal of alcohol can cause delirium tremens in a patient with chronic alcoholism, which can lead to injury to the patient and to others. Evaluate depressed patients for suicidal ideations and treat appropriately.
Special Concerns
Because pseudo-Cushing syndrome may be caused by chronic ingestion of alcohol, alcohol withdrawal syndrome is likely to occur and should be anticipated and prevented.
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Pseudo-Cushing Syndrome excerpt Article Last Updated: Jul 19, 2007
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