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

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.

Evaluating Hypercortisolism

Douglas Stahura D.O.

3/6/2001

Evaluating Hypercortisolism

Traditional definition of Cushing’s Disease is 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

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

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

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

Evaluating HypercortisolismLow dose Suppression testDexamethasone 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)

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

Evaluating Hypercortisolism ACTH levels.

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

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. .

Evaluating Hypercortisolism

Petrosal sinus sampling Demonstrate an ACTH gradient between

petrosal sinus and peripheral blood.