Frequency of clinical signs in patients with Cushing's syndrome and mild autonomous cortisol secretion (MACS): Overlap is common.

BACKGROUND

Cushing's syndrome (CS) can be difficult to diagnose. A timely diagnosis, however, is the cornerstone for targeted treatment, to reduce morbidity and mortality. One reason for the difficulties to identify early on patients with CS might be the presence of a mild phenotype. The aim of the study was to classify the phenotypic landscape of CS. We studied patients with overt CS and mild autonomous cortisol secretion (MACS).

METHOD

The study was part of the German Cushing's registry. Patients were prospectively included at time of diagnosis and the number of comorbidities and clinical signs and symptoms were assessed in a standardized fashion. 129 patients with CS (Pituitary CS, n = 85, adrenal CS, n = 32, ectopic CS, n = 12, respectively) and 48 patients with MACS were included. Patients with clinical signs and/or comorbidities typical for CS and at least two pathological screening tests were classified as having CS. Patients with a 1mg-low-dose-dexamethasone-suppresion-test above 1.8µg/dl without being clinically overt CS were classified as having MACS.

RESULTS

On average, patients with CS had two comorbidities (range 1-3) at time of diagnosis (pituitary CS: 2 (1-3), adrenal CS: 3 (2-4), ectopic CS: 3 (2-4)). Patients with MACS, however, had three comorbidities (range 2-3). Hypertension was the most common comorbidity in all subtypes of CS (78-92%) and in patients with MACS (87%).Of a total of 11 clinical signs, patients with CS had on average five with 28% of patients having between 0-3 clinical signs, 50% 4-7 signs and 22% more than 7 clinical signs. Patients with MACS had on average two clinical signs (range 1-3) at time of diagnosis.

CONCLUSION

The phenotypic landscape of CS is quite variable. The frequency of comorbidities is similar between patients with CS and MACS. A relevant number of patients with overt CS has just a few clinical signs. There is also an overlap in frequency of symptoms and clinical signs between patients with CS and MACS. According to the current guidelines, 96% of our patients with MACS fall into the category ""consideration of adrenalectomy". This should be kept in mind when making treatment decisions in the latter group of patients.

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