30F presents with 3-months of change in facial appearance and hypertension. What would you be thinking?
Open this thread and I'll explain my approach and reveal the final diagnosis.
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@AndreMansoor @grepmeded
Open this thread and I'll explain my approach and reveal the final diagnosis.
@MedTweetorials #MedTwitter #MedStudentTwitter
@AndreMansoor @grepmeded
This patient has Cushingoid faces, also described as moon-faces. It's suggestive of hypercortisolism.
While their are many signs of hypercortisolism, the best ones to look for are:
- Easy bruising
- Facial plethora
- Proximal myopathy
- Striae
While their are many signs of hypercortisolism, the best ones to look for are:
- Easy bruising
- Facial plethora
- Proximal myopathy
- Striae
Of all these signs, the presence of purple >2cm axillary striae is the most specific.
On exam the next step is to look at the skin and abdomen. There may be clues regarding the underlying cause.
- Abdominal mass - adrenal tumour
- Pigmentation - ACTH-secreting tumour
On exam the next step is to look at the skin and abdomen. There may be clues regarding the underlying cause.
- Abdominal mass - adrenal tumour
- Pigmentation - ACTH-secreting tumour
In this case you're suspicious of hypercortisolism.
Step 1: Exclude exogenous steroid use
Steroid use is the most common cause of Cushing's syndrome. It can be in the form of tablets, inhalers and creams.
Step 1: Exclude exogenous steroid use
Steroid use is the most common cause of Cushing's syndrome. It can be in the form of tablets, inhalers and creams.
Step 2. If no obvious steroid use then perform screening tests
- Urinary free cortisol (24 hr)
- Dexamethasone suppression test (1 mg overnight)
- Midnight salivary cortisol
If one of these tests is positive then repeat the other 1-2 tests.
- Urinary free cortisol (24 hr)
- Dexamethasone suppression test (1 mg overnight)
- Midnight salivary cortisol
If one of these tests is positive then repeat the other 1-2 tests.
Once you've confirmed Cushing's syndrome then you need to determine the cause.
Step 3. Test the serum ACTH
<10 ATCH-independent cause
>20 ACTH-dependent dependent
Step 3. Test the serum ACTH
<10 ATCH-independent cause
>20 ACTH-dependent dependent
ACTH-dependent
- DDx pituitary tumour or ectopic ACTH secretion
- Get a high dose dex suppression test
- Pituitary tumour will suppress whereas ectopic ACTH does not
ACTH-independent
- DDx adrenal hyperplasia, adenoma or carcinoma
- Get an adrenal CT
- DDx pituitary tumour or ectopic ACTH secretion
- Get a high dose dex suppression test
- Pituitary tumour will suppress whereas ectopic ACTH does not
ACTH-independent
- DDx adrenal hyperplasia, adenoma or carcinoma
- Get an adrenal CT
In summary:
- The best signs of Cushing's syndrome are easy bruising, facial plethora, proximal myopathy and striae
- Exclude exogenous steroid use then perform screening tests
- If no steroid use and Cushing's syndrome is confirmed then check an ACTH
- The best signs of Cushing's syndrome are easy bruising, facial plethora, proximal myopathy and striae
- Exclude exogenous steroid use then perform screening tests
- If no steroid use and Cushing's syndrome is confirmed then check an ACTH
This patient had Cushing's syndrome from exogenous steroid use from inhalers.
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Until then here's another thread on managing the complications of chronic steroid use. In this case how would you proceed?
Until then here's another thread on managing the complications of chronic steroid use. In this case how would you proceed?
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