darkhorse
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A 14-year-old girl is brought to the office because of a 5-month history of "red lines" on her abdomen and breasts. She says that she has gained 14.1kg (31lbs.) in the past 6 months, and she has not gotten any taller. She used to play on the junior varsity basketball team, but she quit 6 1/2 months ago because "the other girls were mean." Now she comes home after school, watches television on the couch, and "snacks on whatever food is in the cabinet." Menarche was at age 11 and she has been menstruating at regular, 29-day intervals since age 12. She does not take any medications. Her blood pressure is 110/70 mm Hg. Physical examination shows breasts with projection of the areola and papilla forming a secondary mound, an obese abdomen, adult quantity and type of pubic hair, normal external genitalia, and reddish-purple striae on her breasts, abdomen, and outer thighs. She is most concerned about the "lines". At this time it is most appropriate to
A. order a low-dose dexamethasone suppression test (0.5 mg every 6 hours for 48 hours)
B. order a plasma ACTH
C. order a plasma cortisol at 8 a.m. after a 1mg dexamethasone at midnight
D. order a 24-hour urine free cortisol
E. reassure her that the striae are a relatively common issue in adolescence due to rapid body changes
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| bax
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D
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| dr.wad
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D
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| neuroblastoma
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why not A if you wanna do screening test???
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| faraym
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A?
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| darkhorse
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The correct answer is E. This patient has cutaneous striae ("stretch marks"), which are an extremely common occurrence in teenage girls, pregnant women, obese patients, and any other individuals with a rapid change in weight. They are most likely due to weakening and rupture of the preexisting collagen fibers in the dermis caused by the rapid stretching of the skin. Unfortunately, there are not any reasonable, effective treatments for this yet. After she is reassured about the "stretch marks," it is important to discuss increasing her exercise, decreasing her "snacking on whatever food is in the cabinet," and address the emotional issues that led her to quit the basketball team.
All of the other choices are part of the work-up for Cushing syndrome. Cushing syndrome is characterized by increased weight, hypertension, hirsutism, amenorrhea, striae, personality changes, osteoporosis, ecchymoses, edema, weakness, fatigability, and a typical body habitus (buffalo hump, "moon facies", and truncal obesity). The work-up typically begins with a plasma cortisol at 8 a.m. after a 1mg dexamethasone at midnight (choice C) or a 24-hour urine free cortisol (choice D) and then a low-dose dexamethasone suppression test (0.5mg every 6 hours for 48 hours) (choice A). If there is no response to the low-dose dexamethasone suppression test, plasma ACTH (choice B) is measured. If this is high, the syndrome is most likely due to adrenal hyperplasia due to an ACTH-producing tumor. If ACTH is low, an adrenal adenoma is the most likely cause of the syndrome. If the patient is able to suppress her cortisol levels after a low-dose dexamethasone suppression test, the most likely cause of the syndrome is adrenal hyperplasia due to pituitary ACTH secretion. The patient in this case is obese and has striae, however she does not have any other symptoms consistent with Cushing syndrome. Her striae are most likely a result of her rapid weight gain due to a lack of exercise and an increase in the amount of "snacks".
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