Rhea presents with persistant weight gain and lethargy. Please take a history - introduction and rapport A ~ age (36yo), occupation (secretary) A ~ how much do you weigh ? (85 kg) ~ how much weight have vou gained ? (15ke) - over what period of time ? (12 months) ~ noticed any change in your appetite ? (n0) ~ have you noticed any change in bowel habit? (no) - have you been feeling lethargic and tired ? (yes, for quite some time) = have you problems with weight control in the past ?. (no) ~ noticed any altered facial or body appearance? —_ (yes, fuller face) wd = can I see photos ? ced ~ easy bruising and weak skin ? (yes, especially arms and tummy) = had problems with acne 7 (yes) - noticed any increased hair growth ? (yes, very embarrassing) os = muscle weakness (proximal eg hanging up clothes)? /T = bone pain? (osteoporosis) wll - recurrent infections (skin, thrush, URTI) ? (yes) oA + menytiual changes ? (yes) wll - depression or lowered mood ? (yes) wl Questions specific to region of abnormality + visual defects (pituitary adenoma) wll darker ckin (pigmentation due to pituitary ACTH overproduction) ved Rule out hypothyroidism = noticed any lumps in your neck? (no) A + prefer hot or cold weather ? (lots of blankets in summer - no) dl = noticed any ewelling of anklee? — (na), n - past medical history (weight problems, thyroid disease, diabetes, asthma - no) = family history (weight control, thyroid, dlabetes - noy ~ social: difficult being fat. =drugs: nil (steroids. COCs - no) = smokes: nil ETOH: social = allergies: none What is your list of differentials and likely diagnosis ? => Cushing’s disease _ - obesity (increased consumption. ? psychiatric) a hypothyroidism vol ~ heart failure eofWhat investigations would you like to perform ? ~ plasma cortisol (high with loss of diurnal variation) = urinary free cortisol (high) = plasma ACTH. ~ dexamethasone suppression test - CT/MRI brain =? Adrenal scan (radiolabelled cholesterol) - petrosal sinus sampling (compare levels of ACTH central vs peripheral) + vile. FBE, BSL, U&Es, TFTs, LDLs, CAR (cctupit ACTH), vile pituitary hormunc, EG ‘What are the causes of Cushing’s disease + pituitary adenoma (80%) wl ~ adrenal adenoma A = ectopic ACTH secretion a = exogenous steroids fl ‘Mow can you alstingulsn between tne above causes other than nigh plasma cortisol 7 + pituitary adenoma: Wh ACTH igh petrosl ACTH, vs dsurance, cher hormone changes - adrenal adenoma: low ACTH ~ ectopic ACTH secretion: low ACTH, equal ACTH in petrosal sinus vs periphery “A => brain/abdomen CT, CXR, adrenal scan will also assist with diagnosing the cause ‘What may you find on examination in a patient with Cushing’s disease general appearance: central obesity, peripheral wasting, Moon face, buffalo hump, kyphosis .. ss ~ bruising, striae, acne, hirsutism ~ hypertension ” A = proximal myopathy (weakness in shoulders) wll = +H vertebral tenderness (osteoporosis) wr = specific causes: visual disturbance, pigmentation wd ‘What are the complications of Cushing’s disease ? ~ weight gain and altered body image (moon face, buffalo hump - interscapular fat pads) - sion ~ hyperglycaemia ~ electrolyte disturbances (hyperNa+, hypaK+), metaholic alkalosis = osteoporosis + increased risk of infection (immunsuppression) growth retardation in children. “penne illness (depression) = infertility How may you manage a patient with Cushing's disease ? - surgical removal of cause (adrenal, pituitary or ectopic site) ~ follow-up all eascs and wary of hormonal insufficiency ened Cortisol => secreted by adrenal cortex in response to ACTH from the anterior pituitary gland - circadian rhythm, with low secretion in late evening but increases after 3-Shrs sleep and peaks 6am, Altered: physical/emotional stress, light/dark exposure, CNS/pituitary disorders, feedback => devamethasone suppression test: give Img devamethasone midnight & check crtical at 6am No fall in cortisol in morning suggests autonomic secretion e.g pituitary/adrenal adenoma