Fatty dorsal hump

Specialty: Endocrine and metabolic.

• buffalo hump
• dorsocervical fat pad
• supraclavicular fat accumulation

Why it occurs

• Cushing syndrome of any etiology (cortisol stimulates central lipogenesis in specific body areas such as the neck, face and trunk, while promoting lipolysis in extremities)
• Lipodystrophy associated with antiretroviral therapy in patients with HIV (adverse effect of protease inhibitors and nucleoside reverse transcriptase inhibitors that alter the mitochondrial function of adipocytes)
• Obesity of android or central distribution (simple adipose accumulation without demonstrable underlying neuroendocrine dysregulation)
• Madelung syndrome or multiple symmetric lipomatosis (rare metabolic disorder that causes massive deposits of non-encapsulated fat in the neck, shoulders and upper trunk)

Initial workup

Hypercortisolism screening protocol using free cortisol in 24-hour urine and suppression test with low-dose dexamethasone; complete lipid profile and fasting glucose determination; complete blood count and serum electrolytes; bone densitometry of the lumbar spine and femoral neck; and CT of the abdomen if tumor pathology of the adrenal gland is suspected.

Standard management

• Osilodrostat — potent inhibitor of 11-beta-hydroxylase, a terminal enzyme of the cortisol synthesis pathway, used in Cushing's disease refractory to surgery
• Pasireotide — second generation somatostatin analogue with high affinity for the sst5 receptor, indicated to reduce ACTH secretion
• Mitotano — selective adrenolytic and cytotoxic agent of the adrenal cortex, used in the management of advanced adrenal carcinoma
• Rosiglitazone — insulin sensitizer that can modulate fat redistribution in specific forms of insulin resistance, with close cardiovascular monitoring