new_n_lost
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A 65 yr old woman with a long smoking history and Rheumatoid lung disease treated with prednisone for many yrs presents to her internist complaining of increasing weakness and fatigue. On PE the physician notes inc. fat in the upper face, truncal area and the interscapular area. She also notes purple cutaneous striae and several large contusions on the pt's legs. Lab Studies show :-
24 hr urinary free cortisol level of 150 nmol/d (N= < 140nmol/d)
Plasma ACTH of 1 pmol/day ( N= 2-14pmol/day)
Urinary Free Cortisol After High Dose Dexa Challenge 151 nmol/d
Wht is the most likely etiology of the pt. symptoms
A. Adrenal Neoplasm
B. Ectopic ACTH-Secreting tumor
C. Pituitary Adenoma
D. PCOS
E. Prednisone therapy
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| Addicudo
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E. Prednisone therapy
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| Medusin
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Most common cause of Cushing´s is exogenous corticosteroid use so my guess would be...E, prednisone therapy
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| usmlefever
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b small cell lung ca b/c of smoking in exogenous prednisone acth level should dec.
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| usmlefever
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sorry i didn't see the acth level but still my ans is b.
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| inkspot
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Its exogenous corticosteriods use!
RA is a chronic disease and this patient has beem taking steroids for quite some time. She is cushionoid
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| jole
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E
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| sss sss
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a???
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| mytime
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Probably prednisone.
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| Luckyall
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nr 1) the hint is Urinary Free Cortisol After High Dose Dexa Challenge still being high---> is excludes pituitary( would show <50% suppression) , leave adrenal and ectopic ON
nr 2) next best step... look at ACTH level if ACTh high---> is ectopic , if ACTh low is adrenal ( or Glucocorticoid therapy) .
GC therapy would inhibit ACTh --> Zona fasciculata&retic. atrophied----> could not see any incr in Cortisol EVER--> not incr urine free Cortisol
Hope this helps better 
Edited by Luckyall on 05/28/07 - 09:33 AM
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| usmlefever
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so lucky what is your ans istill think its ectopic b
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| new_n_lost
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Any Last Thoughts Guys !!!
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| silver
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A. Adrenal Neoplasm
The question asked a very simple concept--they have given the urinary cortisol level which is high and the ACTH levels are low. After giving a high dose dexa test, the result is still increased cortisol levels (which should have been decreased if it were pituitary). This points towards only one thing which is adrenal neoplasm
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| new_n_lost
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Bang on Target SSS and Silver
Yes this is a presentation of a Adrenal Neoplasm. y cos the Dexa high dose DID NOT SUPPRESS THE FREE CORTISOL LEVELS as it does in Pituitary Adenoma & the ACTH is dec so therefore it has to be a Adrenal Neoplasm.
Choice B says an Ectopic ACTH Tumor = now wudnt the ACTH be increased in Such a Scenario. An Ectopic secreting ACTH Tumor wud give us the following Values: Inc ACTH with Inc Cortisol
Choice C says Pituitary Adenoma well cant be that cos the FREE Cortisol Levels DIDNT DECREASE as they shud after a high dose Dexa stimulation the Value actually inc from the previous level.
Choice D PCOS doesnt give a Cushingoid Picture
Choice E the most Troublesome n yet the most easy to rule out by simple reasoning EXOGENUOUS GC Administration Always DECREASES the FREE URINARY CORTISOL levels cos its not likethe original Cortisol. it be have Both Decreased levels of Free urinary Cortisol & ACTH and negative high dose DEXA test.
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FORUM RULES-- Those who believe in telekinesis, raise my hand. I get enough exercise just by pushing my luck --P4U World.." The pure and simple truth is rarely pure and never simple."
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| new_n_lost
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Believe me i also got this wrong i made the same mistake of just looking at the Prednisone Choice n thinking its definitely that didnt read the question n again and thats y i posted this cos i knew most of us will look th efact cos sometimes minds work in the same direction
So Kudos to those who got it Correct !! 
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| new_n_lost
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and for the same reason i posted the title Dont Enjoy This cos its surely a tricky one 
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| epica
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Good thinking Q for step 1 and step 2
Luckyall, u were right, u are strong in endo
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| new_n_lost
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Luckyall wrote:nobody read my explains, following that line one can never get a Qs wrong  , they were good, i guess nobody loves me in here
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FORUM RULES-- Those who believe in telekinesis, raise my hand. I get enough exercise just by pushing my luck --P4U World.." The pure and simple truth is rarely pure and never simple."
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| inkspot
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a good one! but in exam when you have 50 sec to answer! i think i would have choosen prednisolone! now i m being more careful
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| new_n_lost
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FORUM RULES-- Those who believe in telekinesis, raise my hand. I get enough exercise just by pushing my luck --P4U World.." The pure and simple truth is rarely pure and never simple."
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| rock
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well i am kinda late here...but i choose A so i am feeling good right now
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