Towards Global Eminence K Y U N G H E E U N I V E R S I T Y MGR R2 정수웅 / Pf. 이상열

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y CASE 1

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Case 1: 24/F C.C.) For evaluation of adrenal mass P.I.) 내원 4 달전부터 팔다리에 자반이 생겨 한양대 병원 방 문하여 혈액검사와 소변검사 시행하였지만 이상 없다는 소 견 듣고 지내던 중, both leg edema, amenorrhea 발생하여 내과 외래 방문하여 시행한 초음파 검사에서 adrenal mass 발견되어 further evaluation 위해 입원함.

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y PMHx DM/HTN/Hepatitis/Tuberculosis (-/-/-/-) FHx PHx 음주력 (-) 흡연력 (-) Occupation : 서비스업 HTN, Old CVA

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Review of System  GeneralGeneral weakness (+) Fever (-) Weight loss (+) : 평소 59kg, 49kg  45kg (-4kg/1 달 )  SkinPurpura on both arms & legs Pigmentation (-) alopecia (-)  HEENTHeadache (+) visual disturbance (-) sore throat (-)swallowing difficulty (-)  ChestDyspnea (-) Palpitation (-) Nipple discharge (-)  AbdomenA/N/V/D/C (+/-/-/-/-)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Vital sign: 150/90 mmHg – 88/min – 20/min – 36.1°C Physical Examination  General AppearanceAlert & oriented Generally well-looking appearance  HEENTLN enlargement (-) Neck vein engorgement (-)  ChestCBS without rale RHB without murmur  AbdomenAbdominal Td/Rebound Td (-/-)  Motor, sensory V V

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Appearance Appearance

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y CBC/DC 6700/mm³ g/dL % - 110K/mm³ (Seg : 77%) PT 13.1 sec PT INR 1.03 aPTT 30.0 sec Chemistry Total bilirubin 0.9 mg/dL Pro/Alb 6.8/4.4 g/dL AST/ALT 17/21 U/L BUN/Cr 14/0.7 mg/dL Na/K/Cl 141/3.2/101 mmol/L Ca/P/Mg 8.7/3.3/2.2 mg/dL Total CO mEq/L CRP 0.02 mg/dL ABGA – 43.0mmHg – 102mmHg – 28.7mEq/L – 97.6% Urine hCG : negative Initial Laboratory Findings

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Chest X-ray Chest X-ray

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y EKG EKG

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Abdomen US Abdomen US

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y #1. Adrenal adenoma Cortisol-producing Aldosterone-producing Endocrine inactive Impression

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Abdomen CT Abdomen CT

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Overnight dexamethasone suppression test Serum cortisol16.31 ug/dL 24hr urine collection Free cortisol851.5 ug/24hr(19.5 ~ 115.4) Metanephrine60.5 ug/24hr(52 ~ 341) Normetanephrine47.3 ug/24hr(88 ~ 444) VMA3.5 mg/24hr(0 ~ 8.0) Cr0.6 g/24hr Plasma aldosterone/renin activity ratio Aldosterone81.3 pg/mL(29.9 ~ 158.8) Renin5.61 ng/mL(0.30 ~ 2.90)  Aldosterone/Renin activity Ratio1.5 Adrenal hormone analysis Adrenal hormone analysis

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Low & High Dose Dexamethasone Suppression Test Day1Day2Day3Day4Day5Day6 Day7 24 hrs UFC (ug/day) Cortisol(S) (ng/mL) ACTH 14.5 pg/mL (6~76) Dexa 0.5mg q 6hrsDexa 2mg q 6hrs : plasma cortisol > 50nmol/L (20 ng/mL) after 0.5mg dex q 6hr for 2days : cortisol suppression > 50% after 2mg dex q 6hr for 2days 24 시간 소변 유리 코티솔이 기저치에 비해 90% 이상 억제

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y 75g Oral Glucose Tolerance Test 75g Oral Glucose Tolerance Test 0 min30 min60 min90 min120 min Glucose (mg/dL) Insulin (µU/mL) C-peptide (ng/mL)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y BMD BMD

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Laparoscopic adrenalectomy

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Pathology Pathology

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Clinical Course Clinical Course 2011/7/25 59kg49k g 8/319/14 45kg ~ kg 내과 외래 방문 당시 Purpura amenorrhea 시작 (2011/03) Cushing syndrome 진단 Laparoscopic adrenalectomy 10/6 45kg

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Final Diagnosis #1. Cushing syndrome due to cortisol-producing adrenal adenoma #2. DM #3. Osteoporosis

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y CASE 2

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Case 2 : 45/F 유 O 희 C.C.) For DM control P.I.) F/45, 특이병력 없던 환자로 2 주전 건강 검진시 공복혈 당 280mg/dL 측정되어 10 일전 강동성심병원 내원하여 DM, HTN medication 시작하였음. 이후 혈당조절 잘 되지 않아 본원 외래 통해 입원함

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y PMHx DM/HTN/Hepatitis/Tuberculosis(+/+/-/-) Medication Metformin 1000mg qd Losartan 50mg/HCTZ 12.5mg qd PSHx C-sec (about 10 yr ago) FHx PHx Alcohol/Smoking (-/-) DM,HTN

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Review of System  GeneralFatigue (-) Dizziness (-) Weight loss : 1 년 전 4~5kg 증가, 최근 5~6kg 감소 3 개월 전부터 체중 조절  HEENTHeadache (-) Visual disturbance : 눈 침침함, 4 년전부터 안과에서 안구건조증 진단 후 점안액 사용  ChestDyspnea (-) Palpitation (-) Dyspnea (-)  AbdomenA/N/V/D/C (-/-/-/-/-)  MusculoskeletalArthralgia (-) Myalgia (-) Weakness (-)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Height 154cm Weight 78.4kg BMI 33kg/m 2 Vital sign: 159/100 mmHg – 90/min – 20/min – 36.0°C Physical Examination  General AppearanceAlert & oriented Generally well-looking appearance  HEENTLN enlargement (-) Neck vein engorgement (-)  ChestCBS without rale RHB without murmur  AbdomenSoft but obese abdomen without striae Abdominal Td/Rebound Td (-/-)  Motor, sensory V V

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y CBC/DC 8200/mm³ g/dL % - 257k/mm³ (Seg : 86.9%) Chemistry Total bilirubin 0.9 mg/dL Pro/Alb 6.1/3.3 g/dL AST/ALT 30/53 U/L ALP/rGT 270/338 IU/L BUN/Cr 20/0.7 mg/dL Na/K/Cl 137/3.2/101 mmol/L Ca/P/Mg 8.7/2.5/2.1 mg/dL Glucose 438 mg/dL HbA1c 11.6% Urine analysis RBC 2-4/HP F WBC 2-4/HPF Ketone (-) Protein (+) Nitrite (-) Glucose (++++) Initial Laboratory Findings

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y #1. Newly diagnosed DM #2. Newly diagnosed HTN #3. Hypokalemia Impression Impression

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y 75g Oral Glucose Tolerance Test 75g Oral Glucose Tolerance Test HOMA-IR HOMA-β min30 min60 min90 min120 min Glucose (mg/dL) Insulin (µU/mL) C-peptide (ng/mL)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y 24hr urine collection Free cortisol ug/24hr(19.5 ~ 115.4) Metanephrine31.5 ug/24hr(52 ~ 341) Normetanephrine82.8 ug/24hr(88 ~ 444) Epinephrine 18.2 ug/24hr Norepinephrine 29.3 ug/24hr VMA2.0 mg/24hr(0 ~ 8.0) Plasma aldosterone/renin activity ratio Aldosterone51.1 pg/mL(29.9 ~ 158.8) Renin0.26 ng/mL(0.30 ~ 2.90)  Aldosterone/Renin activity Ratio19.7 Thyroid Function Test Free T ng/dL TSH 0.89 mIU/L T3 42ng/dL Hormone analysis Hormone analysis

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Low & High Dose Dexamethasone Suppression Test Day1Day2Day3Day4Day5Day6 Day7 24 hrs UFC (ug/day) ACTH (P) (pg/dl) Cortisol(S) (ng/mL) Dexa 0.5mg q 6hrsDexa 2mg q 6hrs : plasma cortisol > 50nmol/L (20 ng/mL) after 0.5mg dex q 6hr for 2days : cortisol suppression > 50% after 2mg dex q 6hr for 2days

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Imaging Test Imaging Test

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Final Diagnosis #1. Cushing syndrome due to ACTH-producing pituitary microadenoma #2. DM #3. HTN

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y CASE 3 CASE 3

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Case 3 : 40/F 이 O 정 C.C.) Low back pain onset : 2 달전 P.I.) 40/F, 2 달 전부터 low back pain 있었으나 특별한 치료 없 이 지내오던 중, 2 주전부터 상기 증상 악화되어 외부병원 방문 하여 Compression fracture at L3~L5 진단받았으며, 추가 검사상 Adrenal adenoma 에 의한 Cushing syndrome 진 단되어 adrenalectomy 위해 내원함.

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y PMHx DM/HTN/Hepatitis/Tuberculosis(-/-/-/-) Medication None FHx Unremarkable PHx Alcohol/Smoking (-/-)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Review of System  GeneralFatigue (-) Dizziness (-) Weight gain : 6~7kg over 6 months  HEENTHeadache (-)  ChestDyspnea (-) Palpitation (-) Dyspnea (-)  AbdomenA/N/V/D/C (-/-/-/-/-)  MusculoskeletalArthralgia (-) Myalgia (-) Weakness (-)  GenitourinaryIrregular menstruation

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Height 163cm Weight 52.9 kg BMI 19.9 kg/m 2 Vital sign: 126/88 mmHg – 80/min – 20/min – 36.0°C Physical Examination  General AppearanceAlert & oriented Generally well-looking appearance Acne  HEENTLN enlargement (-) Neck vein engorgement (-)  ChestCBS without rale RHB without murmur  AbdomenSoft abdomen Abdominal Td/Rebound Td (-/-)  MusculoskeletalTenderness over lumbar spine

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y CBC/DC 12660/mm³ g/dL – 38.7% - 329k/mm³ (Seg : 75.6%) Chemistry Total bilirubin 0.28 mg/dL Pro/Alb 7.0/4.2 g/dL AST/ALT 36/35 U/L ALP/rGT 232/259 IU/L BUN/Cr 15/0.5 mg/dL Na/K/Cl 142/3.6/105 mmol/L Ca/P/Mg 8.5/2.6/2.1 mg/dL CRP 0.37 mg/dL HbA1c 6.0% Urine analysis RBC 2-4/HP F WBC 2-4/HPF Ketone (-) Protein (-) Nitrite (-) Glucose (-) Initial Laboratory Findings

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Chest X-ray Chest X-ray

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y EKG EKG

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Lumbar MRI ( 외부 병원 )

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y BMD BMD

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Abdomen CT ( 외부 병원 ) Abdomen CT ( 외부 병원 )

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Low Dose Dexamethasone Suppression Test Low Dose Dexamethasone Suppression Test Day1Day2Day3Day4Day5 24 hrs UFC (ug/day) ACTH (P) (pg/dl) <1 Cortisol(S) (ng/mL) Dexa 0.5mg q 6hrs : plasma cortisol > 50nmol/L (20 ng/mL) after 0.5mg dex q 6hr for 2days

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Laparoscopic adrenalectomy

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Follow-up

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Final Diagnosis #1. Cushing syndrome due to ACTH-producing pituitary microadenoma #2. Osteoporosis #3. Compression fracture at L1,L3~5 #4. Multiple ribs fracture