Internal Medicine

0521779407-C04 CUNY1086/Karliner 0 521 77940 7 June 14, 2007 20:37

Cushing’s Syndrome Cutaneous Larva Migrans 439

➣May require higher than physiologic doses temporarily

➣Education and medical alert bracelet for expected course of post-

cure adrenal insufficiency

■Intermediate:

➣Most patients require maintenance hydrocortisone replace-

ment, plus stress doses for stress, illness, in the year following

successful surgical management of CS

■During medical treatment: follow clinically for symptoms and signs

of cortisol excess or deficiency, 24-hr UFC of uncertain value

■Long-term:

➣Late recurrences not unusual; assess annually for hypercorti-

solism, screen for osteoporosis (DXA scan)

➣Hypopituitarism after pituitary surgery or XRT

➣Nelson syndrome (invasive corticotrophic adenoma, high ACTH

levels) after bilateral adrenalectomy for CS

complications and prognosis

Complications

■Hypercortisolism: immunosuppression, cardiovascular risk, psychi-

atric disturbance, severe insulin resistance+/−glucose intolerance

■Post-cure: 2◦/3◦adrenal insufficiency universal; corticosteroid with-

drawal syndrome; stress doses of corticosteroid during medi-

cal/surgical illness

■Chronic: osteoporosis, increased cardiovascular risk, limited adrenal

reserve, medical alert bracelet for steroid coverage for stress

Prognosis

■Untreated CS: 50% mortality at 5 y

■Cured patients: longstanding adrenal insufficiency for up to 1 y; grad-

ual resolution of weakness, osteoporosis

■Obesity, hypertension, and glucose intolerance may persist

■Recurrence rate of 10–30% for transsphenoidal hypophysectomy

Cutaneous Larva Migrans..............................

J. GORDON FRIERSON, MD

history & physical

History

■Exposure: skin exposure to larvae of dog and cat hookworms (Ancy-

lostoma braziliense, Ankylostoma caninum), usually on beaches

contaminated with dog or cat feces