The subject of this case is a 65-year-old female with syncopal episode. Her husband is the historian, as the patient is not forthcoming with information. Both the husband and the patient appear to be in average health. They live in a very nice neighborhood and kids and grandkids just left after a weekend-long visit. The patient has a 20-year history of pemphigus, a painful chronic autoimmune disorder which causes, �breakdown of the �intracellular cement that holds the epidermal cells together.� (Huether 1105) A result of this is painful blistering of the skin and mucous membranes. For this condition, she takes Prednisone 200mg/day, and has been taking it since ten years ago, at which time the condition became so bad that she was hospitalized for it. Recently, the doctor has also prescribed Vicoprofen 7.5/200 for pain management, as well as topical analgesic gel on swabs which the patient sucks on to relieve the pain of the lesions in her mouth. About this disease, the husband says that some days are better than others. The blistering seems to have flared up in the last couple of weeks.
This patient also has an 8-year history of type II diabetes mellitus, controlled by diet and exercise; a 6-year history of hypertension, for which she takes Lopressor, 25mg/day; 3-month history of depression, for which she is prescribed BuSpar. She visits the doctor regularly to have urine glucose, blood pressure, and urine cortisol assessed. She recently started a job at Wal-Mart as a greeter. Her husband says that she took the job to try to get out of the house once in a while, as she was really getting depressed and moody just sitting around, worse than when she went through menopause.
A general impression and initial assessment reveal that the patient is alert, not oriented, and not talkative or forthcoming with answers to questioning. She is breathing regularly, without airway impairment. She is somewhat heavy in the trunk, with weak-looking extremities. She has thinning hair, and some facial hair growth. Scattered about her skin diffusely are about 40 small blisters in various stages of development and healing. She has a few poorly-healed bruises that suggest she may be on a regimen of coumadin, as they are widespread and in various stages of healing. The husband indicates that she has bruised easily for as long as he can remember, and that the only heart problem the patient has ever had is angina. She�s only had it twice, the first time about seven or eight months ago. Once, he adds, was at a friend�s funeral, walking uphill to the grave and once was after a disagreement with the couple�s 48-year-old daughter last Christmas. The patient�s skin is thinning, especially so on the hands. On the back of her left ankle is a 9 mm, purulent stasis ulcer, not like the other lesions on her skin.
Her pupils are sluggish, but equal. Her blood glucose level is 320 mg/dL and blood pressure is 198/112 mm Hg. Other vital signs don�t raise any concerns . She pulls away from pain and verbalizes discomfort with equal response to bilateral painful stimulus, has no facial drooping, swallows with midline movement of the larynx, and has no evidence of incontinence.
Etiology of Cushing�s Syndrome and the Normal Stress Response
Normal Stress Response
In order to understand the nature of Cushing�s, it is helpful to first fully understand the human stress response, the role of the HPA axis components, the hormones involved in regulation of the axis, and the effects of those hormones on the human body, the main hormones being ACTH and cortisol. Because Cushing�s syndrome is a manifestation of increases in cortisol levels (Ferris 244), it is useful to consider the normal, short-term effects of increased cortisol, as well as more prolonged exposure. In the process, one coincident goal is to begin to formulate a true understanding of the damaging effects of cortisol, regardless of whether it is a result of Cushing�s syndrome, the main focus of this paper, or chronic stress to which certain occupations are subject..
Stress Defined
An oversimplification of stress may be a definition of, �a pressure of force exerted on a body.� (Rathus 513) Psychologically and physiologically speaking, �stress is a demand made on an organism to adapt, cope or adjust.� (Rathus 513) Hans Selye, a pioneer in stress research beginning in the 1930�s, formed what he coined the General Adaptation Syndrome (GAS), in which he proposed the existence of three parts of a stress response, consistent across a variety of origins: the alarm reaction, a resistance stage, and an exhaustion stage. (Rathus 529, DeGroot 1643) Selye also �found that through the mediation of the adrenals, any illness or stress can result in atrophy of the thymus, an effect later obtained with adrenal extracts and pure glucocorticoids,� illustrating that the components of the HPA axis do not only effect one another, but other organs and systems. (DeGroot 1643)
The HPA Axis in Normal Stress Response
In the normal stress response, �the alarm reaction is triggered by the perception of a stressor. This reaction mobilizes or arouses the body in preparation for defense.� (Rathus 531) Huether supports this assertion by stating that, �physiologic stress is a chemical or physical disturbance in the cells or tissue fluid produced by a change, either in the external environment or within the body itself, that requires a response to counteract the disturbance.� (Huether 222) When the brain perceives a stress, a chain of events begins to unfold immediately and instantaneously, and the HPA axis activity is increased, beginning with increased hypothalamic stimulation.
The hypothalamus is situated in the middle and at the base of the cortex and is physically joined to the pituitary gland by the infundibulum, or stalk, of the pituitary gland. It is responsible for maintenance of overall organism homeostasis and influences virtually all tissues in the body. (Marieb 444) Some of the chief functions for which the hypothalamus is responsible include autonomic control (blood pressure, heart rate and force, gastric tract motility, ventilatory rate and depth, pupil size); emotional interpretation and response (perception of fear, rage, pleasure, sex drive); organism thermoregulation (thermostat for blood temperature, initiation of cooling or heat generating processes); regulation of dietary intake (monitoring of glucose and insulin, regulation of feelings of hunger and satiety); regulation of thirst and fluid balance (thirst center, monitoring of osmoreceptors, ADH [posterior pituitary] regulation); sleep/wake cycle regulation (with other brain regions, operates suprachiasmic nucleus, monitoring visual cues of light and darkness); endocrine system function (acts as �helmsman� with releasing hormones and supraoptic/paraventricular nuclei production of ADH/oxytocin). (Marieb 444-5)