A case-based insight into diagnosis and treatment of Cushing’s syndrome

Pituitary surgery is the first-line treatment of Cushing’s disease. However, despite being in remission for months or years, approximately 20-25% may experience recurrence of the disease. The post-operative prognostic criteria for predicting prolonged remission are debatable. Furthermore, the diagnosis of Cushing's disease at an early stage of recurrence presents particular difficulties. Several therapeutic options are possible in patients not cured by surgery. 

Severe Cushing’s syndrome must be urgently diagnosed and the metabolic and other complications managed with alacrity. It is necessary to differentiate ectopic ACTH from Cushing’s disease, using cross-sectional (CT, MRI) and radionuclide imaging, especially 68Ga-dotatate PET scanning and occasionally petrosal sinus sampling. Various medical therapies are available for the rapid oral or parenteral lowering of cortisol.