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Old 08-09-2011
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Question Cushing Syndrome; Steps in the diagnosis

A fat hairy ugly lady goes to her endocrinologist and complains about her beauty.. a Few years ago she was very pretty...The doc thinks its Cushing syndrome so he diagnoses her with a low dose Dexamethasone test...now to find out where its coming from she is suppressed with a high Dexamethasone test..>Pituitary MRI doesn't show anything...What is the next step in Dx?
A) Adrenal Ct
B) Chest Ct
C) Petrosal sinus venous sampling.
D) Full body CT for an ectopic tumor
E) SVC sampling
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Old 08-09-2011
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I am thinking between B or c.....ectopic can be anywhere but most common is in chest so B....But better to rule out pituitary as a source as it may later cause neurological complication...so my answer is c. inferior petrosal sinus venous sampling.
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Old 08-09-2011
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once the pt is confirmed to have high cortisol level by dexamethasone suppression test OR 24 urinary cortisol level ( more accurate ) the next step is to do ACTH level , if it shows high level then its Pituitary source or ACTH producing tumor , then next step would be do MRI head , if MRI is negative this doesnt exclude Pit tumor ( small lesions cant be detect by MRI ) so the next step is to do Petrosal venous sampling , if its High then this is a Pit adenoma if its normal then do CT scan chest to detect ACTH producing tumor .
on the other hand low ACTH level goes with adrenal neoplasia
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Old 08-09-2011
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you guys are right..Most pple just pass up the pituitary just because the MRI has no findings...Microadenomas arent visible on MRI..>So the petrosal sinus sampling has to be done to account for any acth....
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Old 08-09-2011
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c...Petrosal sinus venous sampling.
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Old 08-09-2011
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c...Petrosal sinus venous sampling.
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Old 08-09-2011
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c...Petrosal sinus venous sampling. the answer
done after mri if lesion too small to be seen by mri
if even negtive c...Petrosal sinus venous sampling. then we will search for ectopic acth D...Full body CT for an ectopic tumor
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