[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has crashed his car and his GP identified a bitemporal hemianopia.  Please assess him clinically and discuss your plan with the patient and examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/149509867″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”8″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”2″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has clinical features of Cushing’s disease and the scenario gives a pointer towards a bitemporal hemianopia, supporting the possibility of a rare pituitary aetiology.

The clinical signs exhibited in this video include:

  • Central obesity;
  • Gynaecomastia;
  • Florid abdominal striae;
  • A buffalo hump.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Cushing disease for starters, is not the same as Cushing syndrome (CS). It is characterized by an abnormally high level of cortisol in blood due to an ACTH secreting pituitary tumor. ACTH producing tumors if grow elsewhere in the body, they are called ectopic tumors.

Clinical features of Cushing disease include the symptoms resulting from excess hormone in blood as well as compressive effects of the pituitary tumor (if large enough). Common clinical features in the disease are:

  • Change in physical appearance
  • Moon facies
  • Buffalo hump
  • Easy bruising of skin
  • Abdominal striae (purplish stretch marks)
  • Weight gain (in abdominal area only. Limbs tend to be thin)
  • Plethora (red cheeks)
  • Increased hair growth on legs, face, neck and chest
  • Generalized weakness and fatigue
  • Muscle wasting in upper thigh making getting up from chair difficult
  • Menstrual disorders
  • Reduced sex drive
  • Reduced fertility
  • Hypertension (uncontrollable)
  • Diabetes mellitus (severe)
  • Behavioral changes and mood disturbances
  • Vision loss (macroadenomas)
  • Loss of acuity
  • Color perception affected
  • Hypopituiarism (macroadenoma)
  • Reduced sex hormones, LH and FSH
  • Elevated Prolactin levels (stalk effect)

Due to slow changes, it’s often difficult to diagnose the disease in early stages. Furthermore, elevations in hormones occur in cycles and periods making diagnosis complicated. A detailed history, a thorough physical examination and tests are crucial to reach a diagnosis. Investigations that can be carried out include:

  • Hormone testing
  • 24 hour urine free cortisol measurement
  • Cortisol saliva testing
  • Blood ACTH
  • MRI- detects adenoma in 70% of cases
  • Inferior petrosal sinus sampling (IPSS)-if MRI fails then IPSS is conducted. It distinguishes ACTH producing tumor in pituitary from a tumor elsewhere in the body

Management of Cushing’s disease requires a team of experts and treatment options available for the disease include:

  • Surgery
    • Surgical removal is a long-term solution
    • Cure rate for small tumors- 80-85%
    • Endoscopic technique is very effective
  • Medication
    • Drugs don’t lower ACTH production and don’t shrink tumor but inhibit cortisol production by adrenals
    • Necessary before surgery (ill patients)
    • Indicated if surgery fails
  • Radiation therapy
    • Effective for controlling growth if surgery fails
    • Stereotactic radiosurgery
    • Delayed pituitary failure may occur several years later as a consequence
  • Other options
    • Cortisol replacement by hydrocortisone or prednisolone after surgery.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has clinical evidence of Cushings syndrome and a visual field defect consistent with a pituitary adenoma.  I suspect Cushings disease.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][/vc_column][/vc_row]