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.

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

6. 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

7. 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

10. 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

13. Evaluating Hypercortisolism
Screening Test
Overnight Dexamethasone Suppression
Dexamethasone 1mg 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

15. 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)

18. 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

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

21. 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. .

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