UNIVERSIDAD NACIONAL AUTÓNOMA DE MÉXICO FACULT ACULTAD DE ESTUDIOS SUPERIORES SUPERIORE S PLANTEL PL ANTEL IZTACALA HOSPITAL GENERAL ZONA 29 CLÍNICA INTEGRAL II
HIPERCORTICISMO
Anatomía de las Glándulas Suprarrenales
Las Las glá glá!" !"la lass s"#$ s"#$a$ a$$% $%a al% l%ss %s&á %s&á "'() "'()a! a!as as #*$ #*$ %)( %)(+a +ass !% l*s l*s $(,*%s- )*l*)a!as a )a!a la!* !% la )*l"+a .%$&%'$al s*'$% la )a$a s"#$a+%!(al !%l $(,/ )*$$%s#*!(%&%0 )*$$%s#*!(%&%0 T(%% "a )*l*$a)(/ a+a$(ll%&a * #a$!a- +(!% !% 1 a )+ !% l*g(&"!- %l #%s* !% )a!a "a !% %llas %s !% 33432 g$0 % %l 5*+'$% a!"l&*- 6 !% 37438 g$0 % la +"%$ a!"l&a0 S% %)"%&$a )"'(%$&as % "a )a#s"la a!(#*sa :"% a s" .%; %s&á )"'(%$&a #*$ la
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s(s&%+a %$.(*s* s(+#á&()*- las )"al%s %)%a !% las '$as s% *$(g(a !% " #l%?* % la )á#s"la !% la )a$a #*s&%$(*$ !% la glá!"la 6 #%%&$a % la s"#$a$$%al%s % 5a)%s !% 1 a '$as s( 5a)%$ s(a#s(s- s(g"% %l &$a6%)&* !% l*s .as*s sag">%*s 5a)(a la +B!"la- s( $a+()a$s% % la )*$&%;a0 Histología
La glá!"la #a$%)% !(.(!(!a % "a )*$&%;a %?&%$a 6 "a $%g(/ +%!"la$ (&%$a- #*)* &%,(!a0 La )*$&%;a %s&á <*$+a!a #*$ &$%s ;*as 5(s&*l/g()as :"% s% !%*+(a- !% a)"%$!* )* la !(s#*s()(/ !% s"s )Bl"las ;*a gl*+B$"l*s a- ;*a
La +B!"la s"#$a$$%al %+'$(*l/g()a+%&% !%$(.a !% las )Bl"las %"$*%)&*!B$+()as0 P"%!% )*s(!%$a$s% :"% %s "a #a$&% %s#%)(al(;a!a !%l s(s&%+a %$.(*s* s(+#á&()*0 S(&%&(;a a!$%al(a % " 6 *$a!$%al(a % " 2 0 La #$*!"))(/ !% a!$%al(a %s&á $%g"la!a #*$ %l )*$&(s*l- !% 5%)5* %l
<")(*a+(%&* !% la +B!"la s"#$a$$%al %s&á $%g"la!a #*$ la )*$&%;a s"#$a$$%al0 La +B!"la s"#$a$$%al %s aál*ga a las %"$*as #*s&gagl(*a$%s a":"% las )a&%)*la+(as s%)$%&a!as a)&a )*+* 5*$+*as % l"ga$ !% 5a)%$l* )*+* %"$*&$as+(s*$%s0 Es&as )a&%)*la+(as s% al+a)%a % g$á"l*s )$*+a%s 6 s* l('%$a!as #*$ %?*)(&*s(s % $%s#"%s&a a " %s&>+"l* !% las %"$*as s(+#á&()as #$%gagl(*a$%s0 La .(!a +%!(a !% la *$a!$%al(a 6 !% la a!$%al(a %s +%*$ !% 3 +("&*- s" '(*&$as<*$+a)(/ %s !%'(!a #$()(#al+%&% a la Ca&%)*l4 O+%&(l&$as<%$asa 6 % +%*$ g$a!* a la M**a+(*4*?(!asa Estructura microscpica
Las )Bl"las )$*+a%s- * <%*)$*+*)(&*s !% la +B!"la s"#$a$$%al s* g$a!%s- *.*(!%as- )*l"+a$%s- a)*+*!a!as % (!*s- al.%*l*s * )*$!*%s al$%!%!*$ !% "a $()a $%! !% )a#(la$%s 6 s("s*(!%s .%*s*s :"% !$%a sag$% !% la )*$&%;a0 Las )a&%)*la+(as a!$%al(a@*$a!$%al(aJ )*+#$%!% a#$*?(+a!a+%&% 2 !% la +asa !% .%s>)"las %"$*s%)$%&*$as0 Las :"% )*&(%% *$a!$%al(a s% .% +ás *s)"$as :"% las :"% &(%% a!$%al(a0 Accin de los glucocorticoides
La )*$&%;a s"#$a$$%al #$*!")% +")5as 5*$+*as %s&%$*(!%as- %&$% las )"al%s !%s&a)a %l )*$&(s*l- la al!*s&%$*a 6 l*s a!$/g%*s s"#$a$$%al%s0 LOS GLUCOCORTICOIDES NATURALESK CORTISOL HIDROCORTISONAJ Fa$+a)*)(B&()a El )*$&(s*l &a+'(B lla+a!* 5(!$*)*$&(s*a * )*+#"%s&* FJ %%$)% "a a+#l(a .a$(%!a! !% %<%)&*s s(*l/g()*s- %&$% %llas la <")(/ )a$!(*.as)"la$- %l )$%)(+(%&* 6 la (+"(!a!0 S" s>&%s(s 6 s%)$%)(/ s* $%g"la!as %s&$%)5a+%&% #*$ %l s(s&%+a %$.(*s* )%&$al- :"% %s +"6 s%s('l% a la $%&$*al(+%&a)(/ %ga&(.a #*$ %l )*$&(s*l )($)"la&% 6 l*s gl")*)*$&()*(!%s %?/g%*s s(&B&()*sJ0 El )*$&(s*l s% s(&%&(;a a #a$&($ !% )*l%s&%$*l0 E %l a!"l&* *$+al s% s%)$%&a 3 a 2 +g !% )*$&(s*l al !>a % a"s%)(a !% %s&$Bs0 La &asa !% s%)$%)(/ s(g"% " $(&+* )($)a!(a* !($(g(!* #*$ #"ls*s !% ACTH :"% al)a;a s" +á?(+* % la #$(+%$as 5*$as !% la +a,aa 6 !%s#"Bs !% las )*+(!as0 La gl*'"l(a &$as#*$&a!*$a !% )*$&()*%s&%$*(!%s C=GJ- "a gl*'"l(a 2 s(&%&(;a!a #*$ %l 5>ga!*- )a#&a )as( 9 !% la 5*$+*a )($)"la&% 'a* )($)"s&a)(as *$+al%s0 La C=G a"+%&a % %l %+'a$a;* 6 )* la a!+((s&$a)(/ !% %s&$/g%*s- as> )*+* % %l 5(#%$&($*(!(s+*K !(s+("6% % %l 5(#*&($*(!(s+*- a&% %s&a!*s !% !%)(%)(a !% #$*&%>as 6 % #$%s%)(a !% !%<%)&*s g%B&()*s !% s" s>&%s(s0 L*s )*$&()*%s&%$*(!%s s(&B&()*s- )*+* la !%?a+%&as*a- s% "% % g$a #a$&% a la al'+(a- +ás :"% a la CRG0 La .(!a +%!(a !%l )*$&(s*l % la )($)"la)(/ %s *$+al+%&% !% 7 a 9 +( 6 #"%!% a"+%&a$ )"a!* s% a!+((s&$a 5(!$*)*$&(s*a #$%s%&a)(/ a0 S/l* 3 !%l
)*$&(s*l s% %?)$%&a s( )a+'(*s % la *$(a )*+* )*$&(s*l l('$%K )as( 2 s% )*.(%$&% % )*$&(s*a #*$ a))(/ !% la !%s5(!$*g%asa !% 334 5(!$*?(%s&%$*(!%s % %l $(,/ 6 *&$*s &%(!*s )* $%)%#&*$%s !% +(%$al*)*$&()*(!%s0 M")5*s +%&a'*l(&*s !%l )*$&(s*l s% )*"ga )* á)(!* gl")"$/()* 6 s"lga!*K !%s#"Bs s% %?)$%&a % la *$(a0 Fa$+a)*!(a+(a +%)a(s+* !% a))(/J La +a6*$ #a$&% !% l*s %<%)&*s )**)(!*s %s +%!(a!a #*$ s"s $%)%#&*$%s0 Esas #$*&%>as s* +(%+'$*s !% l*s $%)%#&*$%s ")l%a$%s :"% ()l"6% %s&%$*(!%s- %s&%$*l%s .(&a+(a DJ- 5*$+*as &($*(!%asá)(!* $%&(*()* 6 +")5*s *&$*s )* l(ga!*s !%s)**)(!*s * (%?(s&%&%s0 E a"s%)(a !% l(ga!* 5*$+*al l*s $%)%#&*$%s !% gl")*)*$&()*(!%s s* #$()(#al+%&% )(&*#lás+()*s % )*+#l%*s *l(g*+B$()*s )* las #$*&%>as !% )5*:"% &B$+()* Hs#J0 La 5*$+*a #las+á&()a l('$% 6 la :"% s% %)"%&$a % %l l>:"(!* (&%$s&()(al %&$a a las )Bl"las 6 s% "% al $%)%#&*$ % (!")% )a+'(*s )*<*$+a)(*al%s :"% #%$+(&% :"% s% !(s*)(% !% las #$*&%>as !% )5*:"% &B$+()*0 El )*+#l%* !% $%)%#&*$ "(!* al l(ga!* s% &$as#*$&a %&*)%s % <*$+a a)&(.a 5a)(a %l )l%*- !*!% I&%$a)&a )* %l DNA 6 las #$*&%>as ")l%a$%s0 C*+* 5*+*!>+%$* s% "% a l*s %l%+%&*s !%l $%)%#&*$ !% gl")*)*$&()*(!%s GREJ % l*s #$*+*&*$%s !% l*s g%%s !% $%s#"%s&a0 A!%+ás !% "($s% a l*s GRE- %l $%)%#&*$ "(!* al l(ga!* &a+'(B <*$+a )*+#l%*s )* *&$*s
El #$(+%$* %s $%)%#&*$ !% gl")*)*$&()*(!%s a)&(.a!* #*$ %l l(ga!* "s"al- :"% % %l %s&a!* !% 5*$+*a "(!a $%g"la la %?#$%s(/ !% l*s g%%s !% $%s#"%s&a !% gl")*)*$&()*(!%s0 %l 5GR #"%!% (5('($ l*s %<%)&*s !%l 5GR a)&(.a!* #*$ 5*$+*as s*'$% l*s g%%s !% $%s#"%s&a !% gl")*)*$&()*(!%s- #a$&()(#a!* as> !% la a))(/ s(*l/g()a+%&% (+#*$&a&% !% " (5('(!*$ %!/g%* !% gl")*)*$&()*(!%s0 El $%)%#&*$ !% gl")*)*$&()*(!%s %s&á )*s&(&"(!* #*$ )as( a+(*á)(!*s 6 s% #"%!% !(.(!($ % &$%s !*+((*s <")(*al%s0 El !*+((* !% "(/ !% gl")*)*$&()*(!%s s% l*)al(;a % %l %?&$%+* )a$'*?(l* &%$+(al !% la +*lB)"la0 El !*+((* !% "(/ !%l DNA s% l*)al(;a % la #a$&% +%!(a !% la #$*&%>a 6 )*&(%% "%.% +*lB)"las !% )(s&%>a0 L*s !%!*s !% )() $%#$%s%&a la %s&$")&"$a 'ás()a #*$ la :"% %l !*+((* !% "(/ !%l DNA $%)**)% %s#%)>)a+%&% s%)"%)(as %s#%)>)as !% á)(!*s ")l%()*s0 El !*+((* a+(* &%$+(al #a$&()(#a % la a)&(.(!a! !% &$asa)&(.a)(/ !%l $%)%#&*$ 6 a"+%&a s" %s#%)()(!a!0 La (&%$a))(/ !% l*s $%)%#&*$%s !% gl")*)*$&()*(!%s )* GRE " *&$*s as lla+a!as )*$$%g"la!*$%s !%l $%)%#&*$ !% %s&%$*(!%s- !(.(!(!*s % )*a)&(.a!*$%s 6 )*$$%#$%s*$%s0 L*s )*$$%g"la!*$%s a)&a s($.(%!* )*+* #"%&%s %&$% l*s $%)%#&*$%s 6 *&$as #$*&%>as ")l%a$%s- 6 #*$ %?#$%s(/ !% a)&(.(!a! %;(+á&()a- )*+* a)%&(lasa * !%sa)%&(lasa !% 5(s&*as- #*$ l*s :"% +*!()a la )*<*$+a)(/ !% l*s ")l%*s/+as 6 la )a#a)(!a! !% &$as)$(#)(/ !% l*s g%%s0 L*s %<%)&*s !% l*s gl")*)*$&()*(!%s s% !%'% #$()(#al+%&% a #$*&%>as s(&%&(;a!as a #a$&($ !%l +RNA !% l*s g%%s % l*s :"% la 5*$+*a %%$)% s"s %<%)&*s0 E!ectos "siolgicos
I"6% % la <")(/ !% )as( &*!as las )Bl"las !%l )"%$#*0 Las #$()(#al%s )*s%)"%)(as +%&a'/l()as !% la s%)$%)(/ !% gl")*)*$&()*(!%s * s" a!+((s&$a)(/ s% !%'% a a))(*%s !($%)&as !% %sas 5*$+*as % las )Bl"las0 Alg"*s %<%)&*s (+#*$&a&%s s* #$*!")&* !% $%s#"%s&as 5*+%*s&á&()as #*$ la (s"l(a 6 %l gl")ag/0 Las $%s#"%s&as l(#*l>&()as !% las )Bl"las g$asas a las )a&%)*la+(asACTH 6 5*$+*al !% )$%)(+(%&*- s% a&%a % a"s%)(a !% gl")*)*$&()*(!%s0 E!ectos meta#licos
L*s gl")*)*$&()*(!%s %s&(+"la a la )a$'*?()(asa !% <*s<*%*l#($".a&*- la gl")*sa 474<*s )*+* la l('%$a)(/ !% a+(*á)(!*s !"$a&% %l )a&a'*l(s+* +"s)"la$0 L*s gl")*)*$&()*(!%s a"+%&a las )*)%&$a)(*%s !% gl")*sa sB$()a 6- #*$ &a&*- %s&(+"la la s%)$%)(/ !% (s"l(a % (5('% la )a#&a)(/ !% gl")*sa #*$ las )Bl"las +"s)"la$%s- % &a&* %s&(+"la la l(#asa s%s('l% a 5*$+*as 6 % )*s%)"%)(a- l(#/l(s(s0 La +a6*$ s%)$%)(/ !% (s"l(a %s&(+"la la l(#*gB%s(s 6 % +%*$ g$a!* (5('% la l(#/l(s(s- l* :"% ll%.a a " ()$%+%&* %&* % %l !%#/s(&* !% g$asas )*+'(a!* )* "a +a6*$ s%)$%)(/ !% á)(!*s
g$as*s 6 gl()%$*l 5a)(a la )($)"la)(/0 C*&$('"6% al +a&%(+(%&* !% " a#*$&% a!%)"a!* !% gl")*sa al )%$%'$*0 E!ectos cata#licos $ antiana#licos%
T(%% %<%)&*s )a&a'/l()*s 6 a&(aa'/l()*s % l*s &%(!*s l(<*(!% 6 )*"&(.*- %l +s)"l*- la g$asa #%$( )*+* !%'(l(!a! 6 a!%lga;a+(%&* !% la #(%l- % %l 5"%s* s* )a"sa !% *s&%*#*$*s(s % %l s>!$*+% !% C"s5(g % (+#*% "a l(+(&a)(/ (+#*$&a&% % s" "s* a la$g* #la;*0 E l*s (,*s !(s+("6% %l )$%)(+(%&*0 E!ectos antiin&amatorios e inmunodepresores
L*s gl")*)*$&()*(!%s !(s+("6% !% +a%$a *&*$(a las +a(<%s&a)(*%s !% la (a+a)(/- l* :"% s% !%'% a s"s #$*<"!*s %<%)&*s- s*'$% la )*)%&$a)(/- !(s&$('")(/ 6 <")(/ !% l*s l%")*)(&*s #%$( )*+* *&$*s +%!(a!*$%s !% la (a+a)(/0 Es*s %.%&*s s* +%!(a!*s #*$ "a s%$(% )*+#l%a (&%$a))(*%s )* +*lB)"las !% a!5%s(/ !% l%")*)(&*s )* +*lB)"las s*'$% s"#%$)(%s %!*&%l(al%s :"% s* (5('(!as #*$ l*s gl")*)*$&()*(!%s0 L*s )a+'(*s s* +á?(+*s a las 7 5*$as 6 s% !(s(#a % 2 5*$as0 Ta+'(B (5('% la <")(/ !% l*s +a)$/s&()*s 6 *&$as )Bl"las #$%s%&a!*$as !% a&>g%*s- !(s+("6% la )a#a)(!a! !% la )Bl"la !% $%s#*!%$ a l*s a&>g%*s 6 l*s +(&/g%*s % l*s +a)$/
El s>!$*+% !% C"s5(g s% #$*!")% )*+* $%s"l&a!* !% la %?#*s()(/ )$/()a al %?)%s* !% gl")*)*$&()*(!%s0 E la +a6*$>a !% l*s )as*s s% !%'% al )*s"+* !% gl")*)*$&()*(!%s &%$a#B"&()*s % !*s(s al&as- 6 % +%*$ #$*#*$)(/ a l%s(*%s &"+*$al%s 5(#*sa$(as- a!$%al%s * % *&$as l*)al(;a)(*%s %)&/#()as0 Ha6 !*s &(#*s !% s>!$*+% !% C"s5(g %l %!/g%* 6 %l %?/g%*0 El C"s5(g %!/g%* s% )a$a)&%$(;a #*$ "a #$*!"))(/ !% )*$&(s*l % %?)%s* !%&$* !%l *$ga(s+*- % &a&* :"% %l C"s5(g %?/g%* s% #$%s%&a )*+* )*s%)"%)(a !% " !$*+% !% C"s5(g %!/g%* s% #"%!% )las()a$ a s" .%; % !*s <*$+as #$()(#al%s 3J la <*$+a !%#%!(%&% !% la 5*$+*a a!$%*)*$&()*&$/#()a ACTHJla )"al $%#$%s%&a %l
a !% l*s )as*s0 La )a"sa +ás <$%)"%&% !% %s&% s"'&(#* %s la 5(#%$s%)$%)(/ 5(#*sa$(a !% ACTH J #*$ " a!%*+a )*$&()*&$*#* %&(!a! :"% s% !%*+(a %<%$+%!a! !% C"s5(gJ0 2J la <*$+a (!%#%!(%&% !% la ACTH- :"% )*$$%s#*!% al 3 a 2 !% l*s )as*s 6 :"% s% !%'% "s"al+%&% a a!%*+as a!$%al%s- 6 % +%*$ #$*#*$)(/- al )a$)(*+a a!$%al- a la 5(#%$#las(a a!$%al +a)$**!"la$ * +()$**!"la$ #(g+%&a!a #$(+a$(a0 Etiología ) Síndrome de Cus(ing dependiente de ACTH*
E?)%s(.a #$*!"))(/ !% ACTH !% *$(g% 5(#*sa$(* +()$*a!%*+a +ás <$%)"%&% :"% a)$*a!%*+aJ * !% CRH !% *$(g% 5(#*&alá+()*0 Más <$%)"%&% % +"%$%s0 E?)%s(.a #$*!"))(/ !% ACTH * !% CRH %)&/#()*- g%%$al+%&% a #a$&($ !% Ca$)(*+a #"l+*a$ !% )Bl"las % a.%a *a& )%llJ T"+*$ )a$)(*(!% '$*:"(al- " *&$*s &"+*$%s !%l &(+*- #á)$%as " *.a$(*- )a$)(*+a +%!"la$ !% &($*(!%s000J0 • •
QD%'% s*s#%)5a$s% % #a)(%&%s <"+a!*$%s )* )"a!$* )*s&(&")(*al % 5(#*#*&as%+(a ) Síndrome de Cus(ing no dependiente de ACTH
Ia&$*gB()* #*$ a!+((s&$a)(/ !% )*$&()*(!%s %?/g%*s )a"sa +ás <$%)"%&%J % %s&*s )as*s- las !%&%$+(a)(*%s !% )*$&(s*l % sag$% 6 *$(a s* 'aas0 O$(g% s"#$a$$%al A!%*+a )a"sa s"#$a$$%al +ás <$%)"%&% % a!"l&*sJ Ca$)(*+a )a"sa %!/g%a +ás <$%)"%&% % la ()"laJ • • •
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Fisiopatología
Las !(.%$sas )a"!as !%l S>!$*+% !% C"s5(g s% #"%!% ag$"#a$ % !*s )a&%g*$>as !%#%!(%&%s !% la ACTH % (!%#%!(%&%s !% Bs&a0 Las )a"sas !%l s>!$*+% !% C"s5(g !%#%!(%&% !% la
ACTH ()l"6% la %<%$+%!a! !% C"s5(g !% l*s )as*s !%#%!(%&%s !% la ACTHJ- la 5(#%$s%)$%)(/ %)&/#()a !% la ACTH 2J- 6 la s%)$%)(/ %)&/#()a !% la CRH $a$a .%;JK &*!as )a$a)&%$(;a!as #*$ la 5(#%$s%)$%)(/ )$/()a !% la ACTH 6 %l a"+%&* % la s%)$%)(/ !% )*$&(s*l0 Las )a"sas !%l s>!$*+% !% C"s5(g (!%#%!(%&% !% la ACTH ()l"6% l*s a!%*+as 6 l*s )a$)(*+as )*$&()*s"#$a$$%al%s s%)$%&*$%s !% gl")*)*$&()*(!%- as> )*+* las 5(#%$#las(as s"#$a$$%al%s +()$**!"la$ 6 +a)$**!"la$- &*!*s )a$a)&%$(;a!*s #*$ la s%)$%)(/ a"&/*+a !% )*$&(s*l 6 la s"#$%s(/ !% la ACTH 5(#*sa$(a0
A% En!ermedad de Cus(ing
E la %<%$+%!a! !% C"s5(g s% #$%s%&a "a s*'$%#$*!"))(/ #%$s(s&%&% !% ACTH #*$ %l a!%*+a 5(#*sa$(*0 La 5(#%$s%)$%)(/ !% la ACTH %s !%s*$!%a!a- %#(s/!()a 6 al%a&*$(a- #*$ l* g%%$al )* a"s%)(a !%l $(&+* )($)a!(a* *$+al % las s%)$%)(*%s !% la ACTH 6 !%l )*$&(s*l0 La (5('()(/ #*$ $%&$*a))(/ !% la ACTH s%)$%&a!a a #a$&($ !%l a!%*+a 5(#*sa$(*J #*$ )*)%&$a)(*%s s(*l/g()as !% gl")*)*$&()*(!%s %s&a s"#$(+(!aK as>- la 5(#%$s%)$%)(/ !% ACTH #%$s(s&% a #%sa$ !% s%)$%)(/ al&a !% )*$&(s*l- 6 !a #*$ $%s"l&a!* %?)%s* )$/()* !% gl")*)*$&()*(!%0 Las )*)%&$a)(*%s #las+á&()as !% la ACTH 6 !%l )*$&(s*l .a$>a- 6 % *)as(*%s #"%!% %)*&$a$s% !%&$* !%l (&%$.al* *$+al0 S( %+'a$g*- %l a"+%&* !%l )*$&(s*l l('$% % la *$(a )* la !%+*s&$a)(/ !% )*)%&$a)(*%s sB$()as * sal(.al%s !% )*$&(s*l al&as a 5*$as a.a;a!as !% la *)5% !%'(!* a la #()*s )* %<%$+%!a! !% C"s5(g 9J &(%% $%s#"%s&as %?ag%$a!as !% la ACTH 6 !%l )*$&(s*l #las+á&()*s a la %s&(+"la)(/ )* CRHK 6 s"#$%s(/ ()*+#l%&a % las s%)$%)(*%s !% la ACTH 6 !%l )*$&(s*l % $%s#"%s&a a l*s gl")*)*$&()*(!%s %?/g%*s #*$ %%+#l*- !%?a+%&as*aJ0 S( '(% %s&*s !a&*s s"g(%$% :"% las )Bl"las !%l a!%*+a 5(#*sa$(* #*$ l* g%%$al s* s%s('l%s a la CRH 6 $%la&(.a+%&% $%s(s&%&%s a l*s gl")*)*$&()*(!%s- l*s 5alla;g*s #"%!% !%'%$s%- s%)(lla+%&%- al ()$%+%&* % la )a&(!a! !% )Bl"las s%)$%&*$as !% ACTH0 A#$*?(+a!a+%&% 3 !% l*s #a)(%&%s )* +()$*a!%*+as 5(#*sa$(*s * #$%s%&a ()$%+%&*s (+#*$&a&%s !% la ACTH #las+á&()a % $%s#"%s&a a la CRH0 S% #$%s"+% :"% las )Bl"las )l*al%s !% &al%s #a)(%&%s &(%% " !%<%)&* % %l $%)%#&*$ * #*s$%)%#&*$0
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C% Sindrome de CRH ectpica
E la )l>()a %l s>!$*+% !% CRH %)&/#()a %s (!(<%$%)(a'l% !%l s>!$*+% !% ACTH %)&/#()a0 S( %+'a$g*- !%s!% %l #"&* !% .(s&a '(*:">+()* s% ()$%+%&a las )*)%&$a)(*%s #las+á&()as !% CRH * s"#$(+(!asJ 6 la s%)$%)(/ !% la ACTH %s&(+"la!a #*$ la CRH s% #"%!% s"#$(+($ )* g$a!%s !*s(s !% !%?a+%&as*a * as> % %l s>!$*+% !% ACTH %)&/#()aJ0 Alg"as .%)%s l*s &"+*$%s * 5(#*sa$(*s #$*!")% CRH 6 ACTH %)&/#()as0 '% Tumores suprarrenales
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s"#$a$$%al * #a$&()(#a&%0 La s%)$%)(/ !%l %s&%$*(!% a)*&%)% !% +a%$a al%a&*$(a 6 %#(s/!()a- 6 #*$ l* g%%$al * s% s"#$(+% )* !%?a+%&as*a0 E l*s )a$)(*+as s"#$a$$%al%s %s <$%)"%&% la s*'$%#$*!"))(/ !% #$%)"$s*$%s a!$/g%*s- l* )"al $%s"l&a % 5($s"&(s+* 6 .($(l(;a)(/ !% las +"%$%s a!"l&as- * !% l*s (,*s !% a+'*s s%?*s0 P*$ *&$a #a$&%- % l*s a!%*+as s"#$a$$%al%s la #$*!"))(/ !% #$%)"$s*$%s a!$/g%*s %s&á $%la&(.a+%&% l(+(&a!a0 P*$ &a&*- las +a(<%s&a)(*%s )l>()as !% Bs&*s )*$$%s#*!% #$()(#al+%&% a las !%l %?)%s* !% )*$&(s*l0 S% !%s)**)% la $a;/ #*$ la )"al s% !%sa$$*lla a!%*+as s"#$a$$%al%s- #%$* s% 5a %)*&$a!* +"&a)(*%s a)&(.a!*$as !% l*s $%)%#&*$%s #a$a l*s !$*+% !% C"s5(g (!%#%!(%&% !% ACTH (!")(!* #*$ al(+%&*0 E %s&*s #a)(%&%s %l #B#&(!* (5('(!*$ !% la 5*$+*a gas&$*(&%s&(al GIPJ %s&(+"la s%)$%)(/ !% )*$&(s*l a )a$g* !% " a!%*+a s"#$a$$%al "(la&%$al0 La %?#$%s(/ a*$+al !% $%)%#&*$%s #a$a %l GIP % las )Bl"las !%l &"+*$ s"#$a$$%al #%$+(&% a Bs&as $%s#*!%$ a la (g%s&(/ !% al(+%&* )* " ()$%+%&* % %l )AMP 6 la s"'s(g"(%&% #$*!"))(/ !% )*$&(s*l0 E% Hiperplasia micronodular #ilateral
D(s+("6% las )*)%&$a)(*%s !% la ACTH- 6 %l )*$&(s*l * s% s"#$(+% )* g$a!%s !*s(s !% !%?a+%&as*a0 F% Hiperplasia macronodular #ilateral
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Cuadro clínico
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A +%"!* &a+'(B %?(s&% debilidad muscular - a&$('"('l% a "a +(*#a&>a %s&%$*(!% #$*?(+al !% %?&$%+(!a!%s s"#%$(*$%s % (<%$(*$%s% ()l"s* !% l*s +s)"l*s gl&%*sK % l*s #a)(%&%s )* s>!$*+% !% C"s5(g #*$ ACTH %)&/#()a- la +(*#a&>a #"%!% ll%ga$ a s%$ +"6 (&%sa- ag$a.a!a #*$ la 5(#*#*&as%+(a <$%)"%&% % %s&*s #a)(%&%s0 D% (g"al <*$+a s% #"%!% *'s%$.a$ estrías cutáneas !% )*l*$ $** .(*lá)%*- s*'$% &*!* % a'!*+%- )a!%$as- +a+as 6 )a$a (&%$a !% l*s '$a;*s- a?(las 6 +"sl*s s* +ás <$%)"%&%s % (&%sas % l*s #a)(%&%s /.%%sJ0
La #(%l %s a 6 <$ág(l- a&$/)a- #*$ #B$!(!a !% &%(!* g$as* s"')"&á%*- 6 las %:"(+*s(s 6 l*s 5%+a&*+as a#a$%)% %s#*&á%a+%&% * &$as &$a"+a&(s+*s +>(+*s0 Las 5%$(!as )()a&$(;a l%&a+%&% 6 s% #"%!% *'s%$.a$ á$%as !% acantosis nigricans. E l*s )as*s :"% )"$sa )* s%)$%)(/ a"+%&a!a !% ACTH %?(s&% aumento de pigmentación cutánea - s(+(la$ al !%s)$(&* % la %<%$+%!a! !% A!!(s*- :"% s"%l% s%$ +ás (&%sa % l*s #a)(%&%s )* #$*!"))(/ %)&/#()a0 S* <$%)"%&%s la oligomenorrea * la amenorrea 6- s( %?(s&% 5(#%$a!$*g%(s+*- #"%!% *'s%$.a$s% seborrea- acné- hirsutismo 6 s(g*s !% .($(l(;a)(/ % )as*s g$a.%s0 La HTA moderada- )* $%(a 'aa 6 )* #$%s(*%s !(as&/l()as s"#%$(*$%s a 943++ Hg- %s 'as&a&% 5a'(&"al0 P$*'a'l%+%&% %s&á $%la)(*a!a )* "a %?#as(/ !%l .*l"+% %?&$a)%l"la$ #*$ $%&%)(/
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'iagnstico del (ipercorticismo
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