Weight gain, depression, and amenorrhea

[drnrpatel]

A 34-year-old woman is being evaluated for weight gain, depression and amenorrhea over the past 7 months. She denies prior medical issues, takes no medications and has no allergies. Her blood pressure is 150/95 mm Hg. She is noted to be obese and she has dermal striae. As part of an evaluation she receives a midnight dose of 1 mg of dexamethasone. Her 8 am cortisol level is low normal at 14 mcg/dL. Which of the following is the most appropriate next diagnostic step?

A. Abdominal computerized tomogram scan
B. Pituitary gland computerized tomogram
C. 2-day high-dose dexamethasone suppression
D. Urine 17-hydroxycorticosteroid level
E. Urine 24-hour free cortisol level

[surez18]

ans B. pituitary CT. lose dose dexa suppress d cortisol. so likly to be..

[dryogi]

B.

Pituitary gland computerized tomogram

[qurat21]

the ans is E urine 24hr free cortisol level..!!!!

[drnrpatel]

The correct answer is E. This patient should be evaluated for Cushing syndrome. The single dose overnight dexamethasone suppression test is a screening test in the work up of cortisol excess. Suppression of plasma cortisol to less than 5 mcg/dL implies normal hypothalamic-pituitary-adrenal feedback and excludes Cushing syndrome as the diagnosis. Suppression failure is not diagnostic. A 24-h urine free cortisol level is necessary to exclude or establish Cushing syndrome as the diagnosis.
Imaging procedures should be performed only after a diagnosis of cortisol excess has been established (choice A).
Pituitary scanning (choice B) should be deferred until chemical workup to evaluate the hypothalamic-pituitary-adrenal axis has been completed.
Besides the 24-hour free urine cortisol level, a 2-day low dose dexamethasone suppression trial may be tried to evaluate for cortisol excess (choice C).
Late-onset congenital adrenal hyperplasia (choice D) is characterized by elevated urinary 17-ketosteroids and plasma DHEA sulfate.