msyamp
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A 74-year-old female suffers severe back pain while picking up a basket of clothes. An x-ray reveals a fracture of T12 along with multiple compressed fractures of the vertebrae. Her skin is thin with areas of purpura. She has a serum glucose of 145 mg/dl. Her serum cortisol is normal. If her serum ACTH is decreased, the most likely pathologic finding is:
A Pituitary adenoma
B Adrenal cortical carcinoma
C Adrenal adenoma
D Marked adrenal atrophy
E Bilateral adrenal hyperplasia
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| robin082006
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not sure about the ans, maybe E?
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| Doc2378
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She has MEN I...so the answer should be A.
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| ssrpk
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why do u suppose she has MEN-I? besides ACTH are low.
pt. showing signs of osteoporosis and poor wound healing, goes with cushing's
Low ACTH rules out A and E
Now, malignant adrenal tumors are more likely to be functional than adrenal adenomas, so i'll go with B-Adrenal cortical carcinoma
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| druas
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I will go with C .But why the cortisol level is normal .I think both in adrenal adenoma and carcinoma cortisol level would be high...My thinking..anyways still go with C. Cannot be E b/c cortisol level would be high..
Edited by druas on 01/02/06 - 07:24 AM
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| Geroo
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it can't be cushings CORTISOL is normal!!!
I go with A .it might be non functional pituitary adenoma.
it can be MEN I.the bone fractures are due to hyperparathyroidism.
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| Doc2378
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Ok, the reason wh I think its MEN I is because of the combintion of presenting symtoms:
MEN I has:
1. Pituitary Adenoma (commonly, they are nonfunctioning adenomas. This patient has LOW ACTH)
2. Hyperpituitarism (increased bone resorption- this patient has compression fractures of the vertebral bodies)
3. Panreatic tumor (the patient has a elevated blood glucose level)
Edited by Doc2378 on 01/02/06 - 02:41 PM
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| dharjma
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multiple compressed fractures on xray:
a) osteoporosis (but cortisol is normal?!)
thin skin with purpura may also be due to the fact she is 74? or could it be clotting factor deficiency plus protein deficiency from liver mets?
low ACTH to me sounds like overproduction of free cortisol.
normal overall cortisol could be due to decreased transcortin from liver impairment. but free cortisol levels are still high. so overall cortisol masked and appears normal?
so my closest guess would be b)adrenal cortical carcinoma +liver mets?.
although i really think im reading tooooo much into the question. cant justify it with others though.
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| msyamp
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great brain work by all of you .
BUT THE ANSWER IS MARKED ADRENAL ATROPHY DUE TO CHRONIC USE OF CORTICOSTERIODS.
THIS EXPLAINS EVERY FINDING.
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| Doc2378
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 ...good one MSYAMP!
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| ssrpk
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hahaha, good one, as the title says
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| sturge_weber
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well ya i too thought A till u gave the ans
real good one
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| Geroo
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good question
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| dharjma
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great question! but why is her cortisol normal then?
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| msyamp
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adrenal atrophy so no intrinsic cortisol. may be the "normal level" of cortisol is from medication!! but that EXPLAINS EVERYTHING.
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| Geroo
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normal level of cortisol doesn't explain the bone fractures and hyperglycemia!!!.
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| infliximab
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AGREE WITH GEROO!!!
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| msyamp
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what else can be the answer? answer is D
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