Case Presentation

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Case Presentation

• 49 y/o WF nurse presents with fatigue, weight
  gain of 25 lbs over 8 months, facial fullness.
• PMH- perimenopausal
• PSH- 2 Ceasarean sections
• All- NKDA
• Meds- MVI, Oscald, occ NSAIDs
• Soc- non-smoker, lt3 beers/wk, reg diet
• Fam- parents in 70s, healthy

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Case Presentation

• ROS-
• fatigue, wt gain, occ LE edema(mild),
  irregular menses
• - (denies) hair loss/thinning, dry skin,
  polyuria, polydipsia, polyphasia, hot/cold
  intolerance, indigestion, diarrhea, tremor, bone
  pain.

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Evaluating Hypercortisolism

• Douglas Stahura D.O.
• 3/6/2001

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Evaluating Hypercortisolism

• Traditional definition of Cushings Disease is
  ACTH-producing pituitary tumor, but may be any
  hypersecretion of ACTH, regardless if tumor is
  identified by radiography
• Cushings syndrome characterized by
• Truncal obesity, hypertension, fatigability and
  weakness, amenorrhea, hirsutism, abdominal
  striae, edema, glucosuria, osteoporosis,
  baasophilic tumor of the pituitary

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Evaluating Hypercortisolism

• All cases of endogenous Cushings syndrome are
  due to increased production of cortisol by the
  adrenals
• For pituitary-dependent adrenal hyperplasia
• Women 3Xgt men
• Age of onset 3rd or 4th decade

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Evaluating Hypercortisolism

• Etiology most cases bilateral adrenal
  hyperplasia is due to hypersecretion of pituitary
  ACTH or production of ACTH by a nonendocrine
  tumor
• Small cell bronchogenic
• Thymus, pancreas, ovary
• Medullary carcinoma of thyroid
• Bronchial adenoma

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Evaluating Hypercortisolism

• Screening Test
• Overnight Dexamethasone Suppression
• Dexamethasone 1mg PO _at_ 2400
• 0800 plasma cortisol level
• Normal less than 5 ug/dl
• A normal result implies that the ACTH control of
  the adrenal glands is physiologically normal

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Evaluating Hypercortisolism

• Low dose Suppression test
• Dexamethasone 0.5 mg PO q6h x48h
• Collect 24h urine for Cr/free cortisol levels on
  2nd day
• For normal pituitary-adrenal axis
• Urinary free cortisol lt 30 ug/dl
• Plasma cortisol lt5 ug/dl
• Test is directed at suppressing the PITUITARY
  GLAND! (to show normal function)

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Evaluating Hypercortisolism

• High Dose Suppression Test
• Dexamethasone 2 mg PO q6h x48 h
• Collect 24h urine for Cr/free cortisol levels on
  2nd day
• For normal pituitary-adrenal axis
• Urinary free cortisol lt 30 ug/dl
• Plasma cortisol lt5 ug/dl
• Test is directed at suppressing the Pituitary AND
  Adrenals

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Evaluating Hypercortisolism

• ACTH levels.
• Useful in diagnosing ACTH-independent etiologies.
  Helpful if LOW.

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Evaluating Hypercortisolism

• Dilemma
• Microadenoma of pituitary vs.
• Pituitary-hypothalamic dysfunction vs.
• Ectopic tumor production.
• MRI of pituitary gadolinium enhanced.
• Other imaging to rule out ectopic tumor
  production of ACTH Lung, ovary, thymus.
• .

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Evaluating Hypercortisolism

• Petrosal sinus sampling
• Demonstrate an ACTH gradient between petrosal
  sinus and peripheral blood.

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