Rosen & Barkin's 5-Minute Emergency Medicine Consult (183 page)

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Epiglottitis

CODES

• 464.4 Croup
  
• 464.20 Acute laryngotracheitis without mention of obstruction
  

BASICS

• Cushing disease: Pituitary adenoma producing excess adrenocorticotropic hormone (ACTH)
  
• Cushing syndrome: Excessive glucocorticoid effects
  

• Multiple endocrine neoplasia type I
  
• Carney complex (pigmented lentigines, atrial myxoma, germ-cell tumors with Cushing disease)
  

• Most commonly exogenous administration of glucocorticoids either therapeutically or surreptitiously
  
• Pituitary adenoma secreting ACTH
  
• Adrenal production of cortisol from adenoma, carcinoma, or micronodular disease
  
• Tumor-producing ectopic ACTH:
  
  • Small cell lung carcinoma:
    
    • Most common
      
  • Uterine cervical carcinoma
    
  • Islet cell tumor of pancreas:
    
    • Multiple endocrine neoplasia (MEN) I-type syndrome
      
  • Medullary thyroid cancer
    
  • Pheochromocytoma
    
  • Ganglioneuroma
    
  • Melanoma prostate carcinoma
    
  • Carcinoid tumor:
    
    • Lung
      
    • Pancreas
      
    • GI tract
      
    • Thymus
      
    • Ovary
      

DIAGNOSIS

Suspect if increasing in obesity while failing to maintain height on the growth chart

Cushing syndrome rarely complicates pregnancy, but has been associated with severe pre-eclampsia and HELLP syndrome (
h
emolysis,
e
levated
l
iver function, and
l
ow
p
latelets)

• Cushing disease previously diagnosed
  
• Prior use of corticosteroids
  
• Characteristic appearance should lead to questions concerning change in weight, facial appearance, hirsutism, or psychiatric symptoms
  

• Diagnosis suggested by:
  
  • Abnormal fat deposition with moon facies
    
  • Buffalo hump
    
  • Central obesity with thin extremities
    
  • Supraclavicular fat deposition:
    
    • Above findings raise suspicion in a stressed patient of potentially developing addisonian (adrenal) crisis
      
• Cardiovascular:
  
  • Uncontrolled hypertension
    
• Neurologic:
  
  • Atherosclerotic or embolic stroke
    
  • Pseudotumor cerebri (primarily with exogenous glucocorticoid administration):
    
    • Check fundi
      
• Spinal lipomatosis with cord or nerve-root compression
  
• Gastroenterologic:
  
  • Peptic ulcers
    
  • GI hemorrhage
    
  • Pancreatitis (primarily with exogenous glucocorticoid administration)
    
  • Fatty liver
    
• Psychiatric:
  
  • Toxic psychosis
    
  • Mood disorders (40%)
    
  • Depression
    
  • Memory impairment
    
  • Euphoria
    
• Musculoskeletal:
  
  • Myopathy (proximal weakness)
    
  • Pathologic fractures
    
  • Osteoporosis
    
  • Aseptic necrosis humeral or femoral heads (primarily with exogenous glucocorticoid administration)
    
• Endocrine:
  
  • Glucose intolerance
    
  • Hyperlipidemia
    
  • Amenorrhea, female with male pattern balding, or hirsutism
    
• Hematologic:
  
  • Increased neutrophils
    
  • Decreased lymphocytes and eosinophils
    
  • Opportunistic infections
    
• Ophthalmologic:
  
  • Cataracts (primarily with exogenous glucocorticoid administration)
    
  • Glaucoma (primarily with exogenous glucocorticoid administration)
    
• Dermatologic:
  
  • Purple striae >1 cm in diameter
    
  • Hyperpigmentation: Especially of buccal mucosa (from excess ACTH production)
    
  • Facial plethora
    
  • Thin skin
    
  • Impaired wound healing
    
  • Ecchymoses
    
  • Acne
    
  • Hyperhidrosis
    

• Cannot confirm diagnosis in ED
  
• Anticipate impending addisonian (adrenal) crisis:
  
  • Most frequent and common problem with Cushing syndrome is its recognition with concurrent illness to prevent acute Addisonian crisis
    
• Search for life-threatening conditions:
  
  • MI
    
  • Stroke
    
  • Sepsis
    
  • Pathologic fracture
    
  • Uncontrolled DM
    
  • Psychiatric emergency necessitating admission
    

• Electrolytes, BUN, creatinine, glucose:
  
  • Hypokalemia
    
  • 10% with metabolic alkalosis
    
  • Diminished glucose tolerance (75%)
    
  • 20% overt DM
    
• Urinalysis:
  
  • 50% have glycosuria
    
• CBC:
  
  • Increased WBCs
    
  • Decreased eosinophils
    

• ECG for myocardial ischemia
  
• CXR for tumor-causing ectopic ACTH
  
• Plain films if suspect possible pathologic fractures:
  
  • Delayed bone age
    

Nonemergent testing:

• MRI for pituitary tumor
  
• CT for adrenal carcinoma, adenoma, or hyperplasia
  
• Dexamethasone-suppression test (follow-up study with primary physician):
  
  • If suspicion of endogenous Cushing syndrome exists
    
  • Low-dose (screening test): 1 mg at 11:00
    pm
    with an 8
    am
    cortisol level drawn:
    
    • Low specificity
      
• False-positive results from alcohol, estrogens, spironolactone, phenytoin, barbiturates, and rifampin:
  
  • High-dose dexamethasone-suppression test needed to confirm the diagnosis:
    
    • 2 mg QID of dexamethasone with cortisol level 6 hr later
      
    • Compare day 2 urine-free cortisol and 17-hydroxyketosteroids with baseline levels.
      

• Alcohol-induced pseudo–Cushing syndrome
  
• Obesity
  
• Psychiatric states:
  
  • Depression
    
  • Obsessive–compulsive disorder
    
  • Panic disorder
    
• Physiologic states:
  
  • Chronic stress
    
  • 3rd-trimester pregnancy
    
  • Chronic strenuous exercise
    

TREATMENT

• Acute addisonian (adrenal) crisis under stress may develop with iatrogenic Cushing syndrome
  
• Patients may have extremely labile behavior with violent behavior
  
• Leading causes of death in untreated Cushing syndrome are:
  
  • Infection
    
  • Stroke
    
  • MI
    

• Anticipate addisonian (adrenal) crisis.
  
• Initiate treatment for associated complications:
  
  • MI
    
  • Stroke
    
  • Psychiatric stabilization