Carcinoid tumor of lung with CUSHING’S SYNDROME is a rare condition. We report a 38-year-old man, with a 28-month history of CUSHING’S SYNDROME presented with hypertension, diabetes mellitus, decreased libido, muscle weakness and fatigability, moon facies, buffalo hump, truncal obesity, cutaneous striae, and easy bruisability. Diagnosis was made by measurements of ACTH (149 pg/mL) and cortisol levels (36 μg/dL) and computerized tomography of the chest.

Introduction: Despite the widespread medical use of glucocorticoids, reports of factitious administration of these hormones have been uncommon. We herein report an unprecedented rise in outbreak of CUSHING’S SYNDROME in Tehran among addicts using Tamgesic (a brand of Buprenorphine) to help them through the narcotic withdrawal stage, without knowledge of the glucocorticoid content of the black-market drug. Material and Methods: Case histories of 19 patients with a final diagnosis of iatrogenic Cushing SYNDROME were reviewed. Liquid chromatography/mass spectrometry (LC-Mass) method was used to evaluate glucocorticoid existence in the brand. Results: No Buprenorphine was present in the vials. Each Tamgesic vial contained 0.4 mg of Dexamethasone disodium phosphate and some amount of heroin. The duration of injection abuse and the number of vials used per day was 4.5 (1-18) months and 6.5 (2-20), respectively. Physical findings of the cases were not different from those of the classic endogenous CUSHING’S SYNDROME but their serum cortisol and urinary free cortisol were suppressed. Severe life-threatening complications were demonstrated in five cases. Conclusion: Surreptitious use of steroids resulting in CUSHING’S SYNDROME may be more common in opium addicts; a high degree of suspicion is needed to uncover this disorder. Whenever facing a Cushingoid appearance in addicts, the possibility of using black market drugs with corticosteroid contents should be kept in mind.

Background: Definite diagnosis and treatment of CUSHING’S SYNDROME is still a dilemma. The aim of this study was to evaluate the accuracy of diagnostic tests and follow-up of patients with CUSHING’S SYNDROME. Methods: Two hundred and fifty three consecutive cases with CUSHING’S SYNDROME during 1370-78 were studied. The screening tests were performed in all patients. High dose dexamethasone suppression test (HDDST) and ACTH measurement were carried out. MRI/CT Scan were performed and compared with laboratory data and pathologic specimens as a gold standard test.Results: The age range was 32±11 yrs. The most frequent symptoms were weakness; hypertension, typical striae, and depression. The frequency of hypertension in ACTH dependent case were 77% vs. 36% in adrenal tumors (P< 0.001). HDDST was positive in 99% of micro and 71% of macroadenomas. Adrenal tumors showed 3.6% suppression but none in ectopic cases. HDDST had a sensitivity of 98%, specificity of 97% and accuracy equals to 98%. The frequency of different etiologies was as following: CUSHING’S disease in 64.8%, adrenal tumors in 32.8% and ectopic ACTH in 2.4% of patients. Transsphenoidal surgery (TSS) was performed in 120 patients. The patients were followed for 53±25 months whose remission periods were 46.7±23.8 months (range 4-114 months). Survival analysis showed 93% remission rate in 12mo, 82% in 2yr and only 33% after 5yr. This recurrence didn’t have any platue level.Conclusion: In our study, hypertension was more prevalent in ACTH-dependent CUSHING’S SYNDROME. HDDST had acceptable sensitivity, specificity and accuracy. Lifelong follow up of pituitary adenomas is inevitable in the case of progressive and gradual nature of recurrence in these tumors.

CUSHING’S SYNDROME which is an uncommon but lethal disorder occurs due to many causes. The most common endogenous cause is CUSHING’S disease or pituitary Cushing. The etiology of this disorder is an adenoma in the anterior pituitary. The most important point in the treatment of this disorder is differentiation between CUSHING’S disease (pituitary) and CUSHING’S SYNDROME (adrenal). We can differentiate up to 90% of cases with hormonal test and radiologic anatomy. The incidence ratio of the disorder in females to males is approximately 5:1. Bilateral adrenal hyperplasia, which is seen in CUSHING’S disease, is caused by long adrenocorticotropic hormone (ACTH) secretion. This long acting secretion may cause formation of nodules in adrenals. Sometimes these unilateral nodules may cause misdiagnosis. In this article, two cases of CUSHING’S disease which had been misdiagnosed and led to unilateral adrenalectomy are reported. These surgeries were not effective and after proper hormonal tests approving occurrence of CUSHING’S disease, both cases had Trans-Sphenoidal Surgery (TSS). After surgery the symptoms in the cases decreased. But both patients had a recurrence of the disease. Now, by means of radiotherapy and medical adrenalectomy (ketoconazole treatment) both of them are under control.

A 32-year-old female, gravid two, para one, with CUSHING’S SYNDROME (CS) was admitted to our hospital at 25 week of gestation with severe hypercortisolism. Basal urinary free cortisol (UFC) was elevated about 10 times above the upper limit of normal in two separate times and plasma cortisol failed to suppress after an overnight 1mg dexamethasone suppression test but Adrenocorticotropic hormone (ACTH) level was suppressed. An abdominal non-contrast magnetic resonance imaging (MRI) disclosed a 3-cm right adrenal mass (Fig. 1). Due to her critical general condition, the adrenalectomy was not performed. At 30 week of gestation, by the diagnosis of severe preeclampsia she underwent an emergent cesarean section. Two weeks later, right adrenalectomy was performed via laparotomy. Pathologic examination of the gland showed a benign adrenocortical adenoma. The newborn was a healthy male who weighed 1850 gram. There was no clinical or biochemical suppression of adrenocortical function in child and they were discharged after 40 days.

Nelson’s SYNDROME nowadays a rare entity results from an adrenocorticotropin (ACTH) –secreting pituitary adenoma in patients with refractory Cushing's disease after a therapeutic bilateral adrenal gland removal. We report a case of 25 year old female with CUSHING’S disease who was initially managed with medical treatment, but in view of severe persistent hyper cortisol state was subjected to bilateral adrenalectomy following which she developed Nelson’s SYNDROME after a gap of six years, which was difficult to diagnose because of limited investigations available. Patient was managed with stereotactic radiosurgery (gamma knife surgery).