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Case Presentation

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, Oscal+d, occ NSAIDs Soc- non-smoker, <3 beers/wk, reg diet Fam- parents in 70’s, healthy. Case Presentation.

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Case Presentation

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  1. 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, Oscal+d, occ NSAIDs • Soc- non-smoker, <3 beers/wk, reg diet • Fam- parents in 70’s, healthy

  2. 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.

  3. Evaluating Hypercortisolism Douglas Stahura D.O. 3/6/2001

  4. Evaluating Hypercortisolism • Traditional definition of Cushing’s Diseaseis ACTH-producing pituitary tumor, but may be any hypersecretion of ACTH, regardless if tumor is identified by radiography • Cushing’s syndrome characterized by: • Truncal obesity, hypertension, fatigability and weakness, amenorrhea, hirsutism, abdominal striae, edema, glucosuria, osteoporosis, baasophilic tumor of the pituitary

  5. Evaluating Hypercortisolism • All cases of endogenous Cushing’s syndrome are due to increased production of cortisol by the adrenals • For pituitary-dependent adrenal hyperplasia • Women 3X> men • Age of onset 3rd or 4th decade

  6. 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

  7. Evaluating Hypercortisolism • Screening Test • Overnight Dexamethasone Suppression • Dexamethasone 1mg PO @ 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

  8. 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 < 30 ug/dl • Plasma cortisol <5 ug/dl • Test is directed at suppressing the PITUITARY GLAND! (to show normal function)

  9. 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 < 30 ug/dl • Plasma cortisol <5 ug/dl • Test is directed at suppressing the Pituitary AND Adrenals

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

  11. 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. • .

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

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