Cushing's syndrome

this patient has a moon face with acne,there is truncal obesity and buffalo hump.the skin is thin with excessive bruising and there is purple striae in the andomen.there is proximal muscle weakness.

causes of Cushing syndrome:
Sustained over production of cortisol

Cushing syndrome (non-ACTH dependent)
1-Adrenal adenoma
2-Adrenal carcinoma
3-Glucocorticoid administration

Cortisol ^ , ACTH v

Cushing disease (ACTH dependent)
1-Pit dependent
2-Ectopic ACTH producing tumour
3-ACTH administration

Cortisol ^ , ACTH ^

NB, pigmentation occur with ACTH dependent causes

Features:
1)central obesity
2)hirsutism
3)recurrent infections
4)osteoporosis ( can cause vertebral collapse)
5)olegomenorrhoea
6)hypokalaemia (due to mineralocoticoid activity )
7)water retension ( ADH )
8)hypoglycaemia ( -ve to insulin )
9)hypertension
10)proximal myopathy and wasting

Investigations:

1-screening:
24 hrs free urinary cortisol
Mid night dexamethasone suppression test

2-cofirmation test
For +ve screening test
Depend on demonstration of inappropriate cortisol secretion not suppressed by exogenous glucocorticoid.
Normal individual suppress cortisol to less than 50 nmole/L
low/high dose dexamethasone suppression test

discuss the treatment/managment of this patient.