Cushingoid Facies

Specialty: Endocrine and metabolic.

• full moon face
• hyperemic rounded facies
• Cushing's facial plethora

Why it occurs

• Prolonged exogenous administration of systemic glucocorticoids (iatrogenic cause of Cushing's syndrome due to suppression of the adrenal axis)
• Cushing's disease (ACTH-producing pituitary micro or macroadenoma that bilaterally stimulates the adrenal cortex)
• Primary adrenal adenoma or carcinoma (autonomous secretion of cortisol independent of ACTH)
• Ectopic ACTH syndrome (paraneoplastic production of ACTH by tumors such as small cell lung carcinoma or bronchial carcinoid tumor)

Initial workup

24-hour urinary free cortisol (at least two basal determinations to demonstrate hypersecretion); nocturnal suppression test with 1 mg of dexamethasone orally at 11:00 p.m. measuring plasma cortisol at 8:00 a.m. the next day (cut-off values ​​greater than 1.8 mcg/dL confirm the absence of negative feedback); nocturnal salivary cortisol measured at 11:00 p.m.; determination of plasma ACTH to differentiate dependent or independent origin; and subsequent sellar MRI or tomography of the adrenal glands.

Standard management

• Ketoconazole — imidazole antifungal used at doses of 400-1200 mg/day for its potent capacity for reversible inhibition of adrenal cytochrome P450 enzymes, blocking the synthesis of cortisol
• Metyrapone — inhibitor of the adrenal 11-beta-hydroxylase enzyme, useful for the acute and rapid control of severe hypercortisolism
• Mifepristone — competitive antagonist of the type II glucocorticoid receptor, indicated to treat secondary hyperglycemia in patients with endogenous Cushing's
• Cabergoline — dopamine agonist that acts on the D2 receptors of pituitary tumor cells to inhibit ACTH secretion in selected cases