# Cushing's Syndrome (Referral) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Endocrine Society Guideline on Diagnosis of Cushing's Syndrome 2008 · Egyptian National Drug Formulary - Antimicrobial 2023 (ketoconazole monograph) · Cushing Disease - StatPearls - NCBI Bookshelf (NBK448184) - disease-level clinical article - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Antimicrobial 2023 (ketoconazole monograph) - Cushing Disease - StatPearls - NCBI Bookshelf (NBK448184) - disease-level clinical article ## Treatment metadata - Ketoconazole — 200 mg — oral.solid ## Complete treatment card ```text CUSHING'S SYNDROME (REFERRAL) Sources: Endocrine Society Guideline on Diagnosis of Cushing's Syndrome 2008 · Egyptian National Drug Formulary - Antimicrobial 2023 (ketoconazole monograph) · Cushing Disease - StatPearls - NCBI Bookshelf (NBK448184) - disease-level clinical article Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (12) - Steady weight gain, usually centred on the trunk, is the commonest complaint [weight gain] - Headache, dizziness and blurred vision from the raised blood pressure [blurred vision · dizziness · headache · hypertension] - Passing much urine, thirst, and either a big appetite or none, as sugar climbs - Women: scanty or absent periods, difficulty conceiving or outright infertility [absent periods · infertility] - Men: reduced libido, low energy, tiredness, vague weakness and erectile difficulty [fatigue] - Bruising with little provocation is one of the more telling complaints [bruising] - Weak shoulder and hip muscles: trouble on stairs, rising from a low chair, or squatting - In a child, weight climbing across the centiles while height stalls is the giveaway - Disturbed sleep, with vivid dreams and nightmares - Depression and mood swings, from elation to sudden low, and sometimes psychosis with no prior history [low mood] - Women: excess hair growth and heavy acne; frank virilisation instead suggests adrenal cancer [acne · excess hair · virilisation] - Long-standing disease thins bone: chronic back pain, lost height from collapsed vertebrae, fractures on trivial impact [back pain · collapse] SIGNS - what you find (12) - Most patients do not look like the textbook picture, so suspicion has to be kept high - No single sign clinches it, and the vague ones lead to both over- and under-diagnosis - A rounded, moon-shaped face - Flushed cheeks with prominent small vessels across them - Fat pad at the back of the neck and above the collarbones; the collarbone pads are the more telling - Raised blood pressure [hypertension] - Thin skin bearing broad purple stretch marks over abdomen, thighs or breasts, and bruises after trivial knocks [bruising · stretch marks] - Hair loss in women [hair loss] - Skin darkened all over points to the ACTH-driven forms - The blood pressure can be severe and drug-resistant at presentation, with heart failure or a dilated heart - Screen young adults with thin bone, early hypertension, high sugar, a plethoric face or weak proximal muscles [hypertension] - Also screen for pigmented, palpable stretch marks over 1 cm wide, easy bruising in the young, or an adrenal lesion found by chance [bruising · stretch marks] TESTS (11) - Ask hard about steroid exposure, creams and inhalers included, and about recreational or covert use - Screening is built to catch cases, so it is deliberately sensitive and less specific - It is confirmed when two different first-tier screening tests come back plainly high - Salivary cortisol, at least twice, early morning and late at night, to see whether the daily rhythm survives - A 24-hour urine for free cortisol: throw away the first morning sample, then collect everything - Too little urine gives a false negative, too much a false positive, and poor kidney function lowers the reading - Prove the tablet was taken and absorbed by measuring the dexamethasone level the same morning - Repeat screening when suspicion stays high despite a negative result, or where the disease may be cyclical - Results are skewed by other medicines, dexamethasone metabolism, night shifts, binding globulin changes and sleep disorders - ACTH is pulsed and varies through the day, so it usually has to be repeated before it can be trusted - ACTH persistently under 5 pg/mL means the adrenal or an outside steroid; above 20 pg/mL means ACTH is driving it IF NOT THIS - what else fits (12) - Pregnancy, severe obesity, or melancholic depression can raise cortisol without the disease - Long-term heavy drinking, or diabetes that is badly controlled - Eating disorders, bulimia nervosa and night eating among them - Chronic lymphoedema, lipoedema, partial lipodystrophy or Dercum disease - Hypothalamic obesity syndromes: Prader-Willi, Frohlich and Bardet-Biedl - In children also POMC or leptin deficiency obesity, and Sotos syndrome - Generalised swelling from severe malnutrition, heart failure, cirrhosis with ascites, or nephrotic syndrome - Abnormal bloods without the physical picture: steroids taken from outside, or covert self- administration - Severe physical stress, severe undernutrition or anorexia nervosa - Excessive exercise, including the athlete triad of disordered eating, absent periods and thin bone - Hypothalamic amenorrhoea, or a state of resistance to glucocorticoids - Rarely, cortisol made outside the adrenal, or high cortisol with none of the Cushingoid features Source StatPearls "Hypercortisolism (Cushing Syndrome)" - disease-level clinical article Status traced to the source above 1. KETOCONAZOLE [1st line] Adult Oral: 200 mg once daily; may increase to 400 mg once daily if response is insufficient. - pre-operative bridge / specialist management Peds Specialist pediatric endocrinology management Source Egyptian National Drug Formulary - Antimicrobial 2023 (ketoconazole monograph) Why All oral forms are cancelled in Egypt, but kept as the guideline medical bridge to surgery; specialist sourcing required. Caution Requires urgent endocrinology referral for diagnostic workup (late-night salivary cortisol, 24h urinary free cortisol, dexamethasone suppression test). Black box warning for severe hepatotoxicity; check baseline and regular LFTs. Ketoconazole is a potent CYP3A4 inhibitor with an extensive drug interaction profile. Egypt KIZOL 200MG 10 TAB. (CANCELLED) RAMEDA 21.60 EGP (2.16/unit) -> discontinued FUNGIZOLE 200MG 10 TAB. (CANCELLED) ALEXANDRIA 22.00 EGP (2.20/unit) -> discontinued KETOZOLE 200MG 10 TAB. (CANCELLED) MEMPHIS 22.00 EGP (2.20/unit) -> discontinued NIZORAL 200MG 10 TAB. (CANCELLED) JANSSEN CILAG 33.90 EGP (3.39/unit) -> discontinued ZAKAN 2GM/100ML SHAMPOO 60 ML SIGMA 18.30 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)