**7.1 Clinical presentation**

High cortisol levels have deleterious effects on almost every organ or system in the body. The most common signs and symptoms are glucose intolerance, hypertension, plethoric rounded facies, decreased libido in both sexes, and menstrual irregularities in females [43]. Other manifestations include osteoporosis, skin thinning and easy bruising, buffalo hump, acne, and proximal muscle weakness. In the pediatric age group, CD should be suspected in children who present with rapid weight gain, growth retardation and dorsocervical fat pad. Uncontrolled CD is associated with high mortality with estimated 5 years' survival of 50% [44]. The main causes of morbidity and mortality in untreated patient are myocardial infarction, strokes, diabetes mellitus, and infection. However, even after successful management, patients are at higher risk for lethal cardiovascular incidents up to 5 years after treatment [45].
