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Clinical History – Cushings Remission | UCLA Pituitary Tumor Program

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This was a 61 year old female type 2 diabetes and hypertension which which both have been worsening recently previously diagnosed with primary hypothyroidism and she again 20 or 30 pounds in recent two years have noticed bruising bleeding lower back pain and also note of prominence of the bump on her back and she had phoneless interface and increased her growth her

Past medical history was not unusual for 61 year old i’ll focus anything here that is particularly of relevance and she wasn’t insulin for diabetes she was on medications for her hypertension and her thyroid replacement therapy and so she am presented to her primary care doctor and as often is the case sometimes the the initial workup is somewhat random and she had

A random morning corazon of 29 which is certainly elevated but but not a very good predictor of in terms of diagnosing cushing’s but our uri free cortisol as you can see there was one here in january nine which was very much elevated an upper reference of 45 and this was 227 so clearly meets the three to four fold elevation that we typically like to see although

She also demonstrates another teaching point that she also had fairly unremarkable you only free cortisol not two months later so again the as the recommendations from the endocrine society suggest you need to do several of these two will enter relied cushing’s she had also had a number of dexamethasone suppression tests and this is really a very wonderful and

Extensive work up that we would see from an outside endocrinologist we typically don’t see anything like this often times we have a bunch of data points and no idea whether they were taken before dexamethasone or after dexamethasone it can be a bit of a needle in a haystack but she actually had a full chart and what this demonstrates is that her baseline serum

Cortisol was at 12 and after the standard little dexamethasone suppression test which is 0.5 milligrams every six hours for 48 hours recorders only suppress 27 and again the suppression should be to 1.8 or less a month when david micrograms per deciliter and then this was followed by the so-called high-dose dexamethasone suppression test provided patient takes

2 milligrams to text message on every six hours for 48 hours and here we look more at the degree of suppression from the initial value and the sort of stringent criteria which suggests pituitary origin cushing’s are in ninety percent suppression in serum cortisol and you can see that she met that criteria she suppressed from seven to one microgram per deciliter

So this did a really suggested that she had cushing’s and that it was likely to drew pituitary origin her third function was normal and she had an initial brain mri outside which was read as normal which as we heard earlier doctorwho field is not an uncommon scenario this is her physical exam you can see here this picture of her arms and you can see some of the

Sort of levito that she has the recent sort of wounds and bruising ecchymosis etcetera she was hypertensive and she had a number of these ecchymosis on her arms and legs this is a picture of her or back and i think you’ll agree there’s some prominence there and that typical fish annoyed appearance that we see sort of like almost or the karyotype appearance that

These patients seem to have sometimes and and but you didn’t notice tree i on the abdomen and really again just to make the point that these physical signs are not present in every one but fairly we have to look carefully for them a neurologic exam was fine she had some proximal weakness but but nothing very dramatic this is just a demonstration of her doing her

Sort of squat test and you can see here in the picture that she is quite centrally obese so we we did a couple of other unit record cells and these again were very elevated as you can see both higher than three-fold elevations and in light of her negative outside mri and i think we’re going to see internal mri on a moment but we we elected to do inferior petrosal

Sign of sampling and em in red here on top you see her right inferior petrosal scientists this is on the baseline the x-axis here is time the green is the left inferior petrosal scientists and the blue is the peripheral blood of the entry of any camera on what does demonstrates very clearly is that a baseline she had a central to peripheral acth gradient looking

At the right petrosal entry of chosen silence to the peripheral blood which was 25 so clearly higher than 2 which is the typical cut up and following crh these presumed tumors cortico tropes released a burst of acth leading to this even higher gradient after see our hitch about two minutes afterwards of 87 so this study would suggest that this patient has central

Cushing’s and as dr. ol freda said it’s not a really good predictor by any means but if we were going to say which side the lesion was likely to be on we would say the right side but probably only a 60-40 predictor

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Clinical History – Cushings Remission | UCLA Pituitary Tumor Program By UCLA Health