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Corticotropin-releasing hormone stimulation

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Article in JAMA The Journal of the American Medical Association May 1993
DOI: 10.1001/jama.269.17.2232 Source: PubMed

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 Corticotropin-Releasing Hormone
Stimulation Following Low-Dose
Dexamethasone Administration
A New Test to Distinguish Cushing's Syndrome
From Pseudo-Cushing's States
Jack A. Yanovski, MD, PhD; Gordon B. Cutler Jr, MD; George P. Chrousos, MD; Lynnette K. Nieman, MD

Objective.\p=m-\The biochemical and phenotypic presentation of mild hypercortiso- MANY of the laboratory abnormalities
lism in Cushing's syndrome is often indistinguishable from that seen in pseudo\x=req-\ that are characteristic of Cushing's syn
Cushing's states such as depression. Both dexamethasone suppression and drome,1 such as elevated urine free Cor
tisol and 17-hydroxycorticosteroid ex
corticotropin-releasing hormone (CRH) stimulation tests have been used individu-
ally to distinguish these conditions, but neither approach has achieved a diagnostic cretion, disruptions in the normal diur
nal pattern of plasma cortisol secretion,
accuracy greater than 85%. Therefore, we sought to develop a combined and lack of suppression of plasma cor
dexamethasone-CRH test that would take advantage of the altered sensitivity of tisol after administration of 1 mg of dex-
patients with Cushing's syndrome to both dexamethasone and CRH and would amethasone, may be seen in other con
achieve greater accuracy in the diagnosis of Cushing's syndrome. ditions. Situations that cause these Pseu
Design.\p=m-\Prospectivecohort study. do-Cushing's states include long-term,
Setting.\p=m-\Tertiarycare research hospital. active alcoholism and withdrawal from
Patients.\p=m-\Atotal of 58 adults referred for evaluation of mild hypercortisolism ethanol intoxication,23 stressful condi
(urine free cortisol level <1000 nmol/d). The diagnosis of Cushing's syndrome was tions such as surgery or severe illness,4
confirmed at surgery in 39 patients. The diagnosis of a pseudo-Cushing's state was renal failure,5 anorexia and bulimia ner
made in 19 patients on the basis of extended follow-up (mean, 28 months) without vosa,6"8 the depressed phase of affective
progression of cushingoid features. disorders,910 primary glucocorticoid re
Intervention.\p=m-\Thelow-dose dexamethasone suppression test, the CRH stim- ceptor resistance,11 and severe obesi
ulation test, and the CRH stimulation test started 2 hours after completion of low\x=req-\ ty.912 While the context and physical
examination may provide important
dose dexamethasone suppression (the dexamethasone-CRH test) were per- clues that a particular hypercortisolem-
formed in all patients. ic patient does not have Cushing's syn
Main Outcome Measures.\p=m-\Sensitivity,specificity, and accuracy of the three drome, definitive diagnosis may be quite
procedures for diagnosis of Cushing's syndrome were calculated from plasma cor- difficult in obese patients with mild hy-
ticotropin, plasma cortisol, urine free cortisol, and urine 17-hydroxycorticosteroid percortisolism, hirsutism, hypertension,
values. or depression. Thus, such patients may
visit their internist, family physician,
Result.\p=ml-The ow-dose dexamethasone suppression test had 74% specificity,
69% sensitivity, and 71% diagnostic accuracy, using the standard criterion gynecologist, psychiatrist, or other sub-
specialist, complaining of symptoms and
(17-hydroxycorticosteroid excretion level >11.0 \g=m\mol/d on the second day of dex- exhibiting signs consistent with Cush
amethasone administration). With a urine free cortisol criterion for Cushing's syn-
ing's syndrome. Further evaluation of
drome of greater than 100 nmol/d, the low-dose dexamethasone suppression test these patients may then reveal 24-hour
had 100% specificity, 56% sensitivity, and 71% diagnostic accuracy. The CRH urine excretion of free cortisol or 17-
stimulation test without dexamethasone pretreatment had 100% specificity, 64% hydroxycorticosteroid compatible with
sensitivity, and 76% diagnostic accuracy. The diagnostic accuracy of the the diagnosis of mild Cushing's syndrome
dexamethasone-CRH test for Cushing's syndrome was significantly greater than or a pseudo-Cushing's state.
the accuracy of either the low-dose dexamethasone test or the CRH test alone The hypercortisolism of pseudo-Cush
(P<.01). A plasma cortisol concentration greater than 38 nmol/L measured 15 min- ing's states is believed to be mediated
utes after the administration of CRH correctly identified all cases of Cushing's syn- through increased hypothalamic secre
tion of corticotropin-releasing hormone
drome and all cases of pseudo-Cushing's states (100% specificity, sensitivity, and
diagnostic accuracy). From the Developmental Endocrinology Branch,
Conclusion.\p=m-\Thedexamethasone-CRH test is a more accurate test to distin- National Institute of Child Health and Human Develop-
guish Cushing's syndrome from pseudo-Cushing's states in patients with mild ment, National Institutes of Health, Bethesda, Md.
Reprint requests to Bldg 10, Room 10N262, Nation-
hypercortisolism. al Institutes of Health, Bethesda, MD 20892 (Dr
(JAMA. 1993;269:2232-2238) Yanovski).

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 (CRH) in the context of a hypothalamic-
pituitary-adrenal axis that is otherwise
appropriately restrained by negative
cortisol feedback. In contrast, hypotha-
lamic CRH secretion is suppressed by
the hypercortisolism of true Cushing's
syndrome, which is less responsive to
the negative feedback of exogenous glu-
cocorticoid.8 Thus, in comparison with
true Cushing's disease, patients with
pseudo-Cushing's states show a dimin
ished response to administration of ex
ogenous CRH and a greater inhibition
of cortisol production by glucocorticoids.
These concepts form the basis for tests
used in the differential diagnosis of hy
percortisolism. The low-dose dexa-
methasone suppression test, in which
17-hydroxycorticosteroid excretion is
measured during administration of dexa-
methasone at a rate of 0.5 mg every 6
hours for 2 days, has been used since its
description by Liddle in I960.13 A 17-
hydroxycorticosteroid excretion value
greater than 11.0 (4 mg/24 h) on
the second day of dexamethasone ad
ministration is considered evidence for
Cushing's syndrome.1415 However, this
test may misclassify as many as 6% of
patients with Cushing's syndrome and
up to 15% of patients with pseudo-Cush
ing's states.9"18 The CRH stimulation test,
while useful in distinguishing between
pituitary and ectopie secretion of adreno-
corticotropin,19 is of limited usefulness
in the differential diagnosis between
pseudo-Cushing's states and Cushing's
disease. Although individuals with de
pression have, on average, significantly
blunted adrenocorticotropin and corti
sol responses to CRH, there is a large
overlap with the responses of patients
with Cushing's disease.20"22
Inability to distinguish patients with
a pseudo-Cushing's state from patients
with Cushing's disease exposes such
pseudo-Cushing's patients to the risk of
unnecessary transsphenoidal explora
tion and, when the hypercortisolism is
not cured by surgery, to pituitary irra
diation. Conversely, if mild Cushing's
disease is diagnosed incorrectly as a
pseudo-Cushing's state, delay in treat
ment may have serious adverse conse
quences for the patient's mental and
physical health.
To address the need for an improved
laboratory test to differentiate Cush
ing's disease from pseudo-Cushing's
states, we evaluated the diagnostic ef
ficiency of a new test that combined CRH
stimulation with low-dose dexametha
sone suppression (the dexamethasone-
CRH test) by examining the effects of
dexamethasone pretreatment on CRH-
stimulated cortisol and adrenocorticotro
pin levels. We hypothesized that, at a
dexamethasone dose sufficient to sup-
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Table 1.Clinical Characteristics of Patients With Mild
No. of
Diagnosis Patients Age, y Female, % Weight, kg Index, kg/m2
Cushing's disease_35_42.913.6t_74_87.9 22.7
Ectopie adrenocorticotropin_2_25.02.8_50_74.927.5_26.44.8
Primary adrenal disease_2_36.05.7_50_79.1 21.6_29.86.1
Pseudo-Cushing's state 19 31.6 11.4
*Results are shown as meanSD.
fP<.005, Cushing's disease vs
press normal cortisol production, pa
tients with pseudo-Cushing's states
would exhibit low basal plasma cortisol
and adrenocorticotropin levels and a di
minished response to exogenous CRH.
By contrast, patients with Cushing's dis
ease would have higher basal cortisol
and adrenocorticotropin levels after ad
ministration ofdexamethasone and have
greater peak values after CRH when
compared to patients with pseudo-Cush
ing's states.
METHODS
Patients
A total of 58 patients admitted to the
National Institutes of Health, Bethes-
da, Md, from June 1987 through June
1991 for evaluation of hypercortisolism
were studied prospectively. Each had a
history of mild hypercortisolism docu
mented by urine free cortisol levels be
tween 250 and 1000 nmol/d (normal, 50
to 250 nmol/d). Each patient who un
derwent a 1-mg overnight dexametha
sone suppression test had an 8 AM cor
tisol concentration greater than 138
nmol/L (5 g/dL). None had renal or
hepatic disease. Each subject gave writ
ten consent for the administration of
ovine CRH as approved by the institu
tional review board of the National In
stitute of Child Health and Human De
velopment.
A presumptive diagnosis of Cushing's
syndrome was made on the basis of the
combination of physical examination, en
docrine studies, and radiologie evalua
tions.1915^ The diagnosis of Cushing's
syndrome was considered confirmed only
when verified by a pathological speci
men or, in those cases of Cushing's dis
ease where no tumor was found, when
clinical and laboratory remission result
ed after transsphenoidal surgery. The
diagnosis of a pseudo-Cushing's state
was based on lack of features of severe
Cushing's syndrome at initial presenta
tion (such as marked central adiposity,
cutaneous atrophy, proximal myopathy,
and large purple striae), preservation of
some diurnal variation of plasma corti
sol, and a lack of progression of the lab
oratory values, the clinical signs, and
the symptoms of Cushing's syndrome
over an observation period of at least 17
months. Of the 58 patients, 35 had Cush-
Hypercortisolism*
Body Mass
33.49.2 +
68 94.429.7
+ 33.910.1
pseudo-Cushing's states (f test).
ing's disease, two had ectopie produc
tion of adrenocorticotropin, two had pri
mary adrenal disease, and 19 had pseudo-
Cushing's states (Table 1).
All 19 patients with pseudo-Cushing's
states underwent pituitary magnetic res
onance imaging; however, none had an
abnormal examination. Most were obese,
and their weight and body mass index
were not significantly different from that
of patients with surgically confirmed
Cushing's disease (Table 1). Psychiatric
consultation was also obtained in all but
one of the patients diagnosed with a
pseudo-Cushing's state. Based on the
psychiatric Diagnostic and Statistical
Manual of Mental Disorders, Revised
Third Edition24 criteria, one was diag
nosed with an eating disorder not-oth
erwise-specified, one was found to have
withdrawal from substance abuse, nine
had a current depressive episode, major
depression, or a history of a major de
pressive episode, one had bipolar illness,
three met criteria for an undifferenti-
ated somatoform disorder, one had an
adjustment disorder with mixed emo
tional features, one had avoidant per
sonality disorder, and two had no evi
dent psychiatric diagnosis. The minimum
period of follow-up was 17 months. The
average period of follow-up was 28
months. Nine have been followed up for
less than 2 years, six for 2 to 3 years, and
four for more than 3 years. Thirteen
(68%) of the 19 have had resolution of
hypercortisolism during follow-up.
Study Protocol
The 24-hour urine excretion of free
cortisol, 17-hydroxycorticosteroid, and
creatinine was measured for 2 days while
patients took no glucocorticoids and sub
sequently while they were receiving 0.5
mg of dexamethasone orally every 6
hours for 2 days starting at 6 AM (the
low-dose dexamethasone suppression
test), as described previously.25 The in-
tra-assay and interassay variabilities
were, respectively, 4% to 11% and 6% to
18% for urine free cortisol, 5% to 14%
and 6% to 21% for 17-hydroxycortico
steroid, and 1% and 2% for creatinine.
Each subject also underwent two 8
AM CRH stimulation tests. Ovine CRH
(Bachern, Torrance, Calif) was admin
istered as an intravenous bolus injec-
 Fig 1.Basal 24-hour urine collections in 58 patients with hypercortisolism. Patients were selected If they had a urine free cortisol level between 250 and 1000
nmol/d. Left, Urine free cortisol excretion. Right, 17-hydroxycorticosteroid excretion. Closed circle indicates Cushing's disease; triangle, ectopie adrenocorticotro
pin; square, primary adrenal disease; and open circle, pseudo-Cushing's states.

Fig 2.Results of low-dose dexamethasone suppression test In 58 patients with hypercortisolism. Criteria shown have 100% specificity. Left, Urine free cortisol
on fourth day of low-dose dexamethasone test. Right, 17-hydroxycorticosteroid excretion on fourth day of low-dose dexamethasone test. Definition of symbols as
In Fig 1. Horizontal lines indicate criterion levels.

tion at a dose of 1 g/kg of body weight.
Plasma samples were assayed for cor
tisol and adrenocorticotropin by Hazel-
ton Laboratories, Vienna, Va, at four
basal time points (-15, -10, -5, and 0
minutes) and then at 5,15,30,45, and 60
minutes after CRH administration. The
first CRH test was performed while the
patient took no glucocorticoids. A sec
ond CRH stimulation test (the dexa
methasone-CRH test) was performed 2
hours after the patient had completed a
course of 0.5 mg of dexamethasone oral
ly every 6 hours for eight doses, start
ing at noon 2 days before the dexa
methasone-CRH test. Thus, the last dose
of dexamethasone was administered at
6 AM, 2 hours before the scheduled start
of the dexamethasone-CRH test. Plas
ma cortisol and adrenocorticotropin lev
els were obtained at the aforementioned
times. The sensitivity for the adreno
corticotropin assay ranged from 0.9 to
2.2 pmol/L and for cortisol from 5.5 to 22
nmol/L. The intra-assay and interassay
variabilities were 7% to 12% and 12% to
25% for adrenocorticotropin, and 6% and
13% for cortisol. Each cortisol sample
was also measured in a second cortisol
assay (Abbott TDX kit, Abbott Labo
ratories, North Chicago, 111). Results
were quite similar, and each cut point
identified using the Hazelton assay had
the same diagnostic accuracy for Ab
bott kit cortisol determinations. There
fore, only results from the Hazelton cor
tisol assay were reported. Each admin
istration of dexamethasone was sepa
rated by at least 2 days to allow for
recovery between tests.
Data Analysis
Data were analyzed on a Macintosh
Ilfx with Superanova and StatView II
(Abacus Concepts Ine, Berkeley, Calif).
Analysis of variance with repeated
measures (with logarithmic data trans
formation, where appropriate) was
performed to detect between-group
and time-related differences. Post hoe
tests were performed, where appro
priate, and interpreted with the
Bonferroni adjustment for multiple
comparisons.
The receiver operating characteris
tics26 of each test for the diagnosis of
Cushing's syndrome were then deter
mined using the RuleMaker program
(Digital Medicine Ine, Hanover, NH).
Sensitivity, specificity, positive and neg
ative predictive values, and diagnostic
accuracy27 were calculated for each test
variable at multiple criteria. For each
test, the variables and criteria with the
highest sensitivity, given 100% speci
ficity for the diagnosis of Cushing's syn
drome, were identified and used for be
tween-test comparisons. For the low-
dose dexamethasone suppression test,
criteria were determined for urine free
cortisol and 17-hydroxycorticosteroid
levels obtained on day 2 (no dexametha
sone) and day 4 (during dexamethasone),
and for the percentage of suppression
by dexamethasone on day 4 compared
with day 2. The 17-hydroxycorticoste
roid excretion was also corrected for cre
atinine excretion: but since results were

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 Table 2.Comparison of Criteria Chosen to Yield 100% Specificity for Diagnosis of Cushing's Syndrome
in 58 Patients With Mild Hypercortisolism*

Positive Negative
Specificity, Predictive
Sensitivity, Predictive Diagnostic
Test Variable Criterion_%_ %
Value, % Value, % Accuracy, %
Low-Dose Dexamethasone Test
17-0CHSday4 >11.0 / 74_ 69 84
17-OCHSday4 >14.6 /d 100 54 100 51 69
Urine free cortisol
day 4_ >100 nmol/d 100 56 100 53
CRH Test Without Dexamethasone Pretreatment
Cortisol sum of
post-CRH levels >3450nmol/L 100 64 100 76
- -1- -
CRH test peak 0 10 20 30 40 50 60
corticotropin >35.0 pmol/L 100 13 100
Dexamethasone-CRH Test
Basal cortisol
(before CRH) >38.0 nmol/L 100 90 100 84
Cortisol 15 min
after CRH >38.0 nmol/L 100 100t* 100 100tt 100
Corticotropin 30 min
after CRH >3.5 pmol/L 100 74 100 66 83

"Criteria for each test variable were derived from receiver operating characteristic analysis.26 Results are given
for the standard low-dose dexamethasone criterion of 17-hydroxycorticosteroid (17-OCHS) excretion levels greater
than 11 /d, and for criteria chosen to yield 100% specificity for the diagnosis of Cushing's syndrome. When the
tests are compared under these conditions, the dexamethasone-corticotropin-releasing hormone (CRH) test, 15-
minute cortisol value has a significantly greater sensitivity and diagnostic accuracy than any of the other tests.
tP<01, dexamethasone-CRH test 15-minute cortisol vs low-dose dexamethasone suppression test, or CRH test
performed without dexamethasone pretreatment. - -1-1-1-r
tP<.05, dexamethasone-CRH 15-minute cortisol vs dexamethasone-CRH test basal cortisol or dexamethasone- 0 10 20 30 40 50 60
CRH corticotropin. Time, min
not improved by this addition, these data responses between the two groups.
are not presented. For the CRH stim The low-dose dexamethasone test had Fig 3.Results of corticotropin-releasing hormone
stimulation test, without low-dose dexamethasone
ulation tests, criteria were established 74% specificity, 69% sensitivity, and 71%
pretreatment. Top, Plasma adrenocorticotropin val
for adrenocorticotropin and cortisol val diagnostic accuracy for the diagnosis of ues. Bottom, Plasma cortisol values. Means and
ues at each individual time point and for Cushing's syndrome when the standard SEMs are given. Definition of symbols as in Fig 1.
the peak response. Criteria were also criterion, 17-hydroxycorticosteroid ex
determined for the sum of all values cretion level greater than 11 /d on
during CRH tests, for all combinations the second day of dexamethasone ad during the CRH test, which yielded 13%
of the sums of the 5-, 15-, 30-, 45-, and ministration, was used (Fig 2 and Table sensitivity and 41% diagnostic accuracy
60-minute post-CRH time points, and 2). To achieve 100% specificity, a crite (Table 2). The best sensitivity (64%) with
100% specificity was obtained using the
for peak excursion of the response from rion for Cushing's syndrome based on
criterion of a sum of post-CRH cortisol
the baseline. Correlated 2x2 tables were 17-hydroxycorticosteroid level greater levels greater than 3450 nmol/L (Fig 4),
constructed for comparison of test cri than 14 /d was required; this yield
which was significantly better than the
teria, and Cochran Q statistics were in ed 54% sensitivity and 69% diagnostic
terpreted with the Bonferroni adjust accuracy (Table 2).
sensitivity based on the adrenocorti
ment for multiple comparisons. A diagnostic accuracy of 71% was cotropin criterion (P<.02).
achieved using a criterion for Cushing's Attempts to find criteria with im
RESULTS syndrome based on urine free cortisol proved diagnostic accuracy by combin
Low-Dose Dexamethasone level greater than 100 nmol/d (36 g/24 ing results from the low-dose dexa
methasone suppression test with those
Suppression Test h) on the second day of dexamethasone from the CRH test without dexametha
administration (Fig 2 and Table 2). With
Urine 17-hydroxycorticosteroid, free sone pretreatment did not improve di
this criterion, urine free cortisol had
cortisol, and creatinine measurements 100% specificity, but only 56% sensitiv agnostic accuracy over that found with
were available before and during dex the low-dose dexamethasone test alone.
amethasone administration from all 58 ity (P=.48 vs 17-hydroxycorticosteroid).
CRH Test With Dexamethasone
patients (Figs 1 and 2). Daily creatinine CRH Stimulation Test Without Pretreatment
measurements varied by no more than
17%, and the range of individual values Dexamethasone Pretreatment All patients completed the dexametha
was between 8.9 and 25.2 mmol/d (1.0 to Data were available from all patients sone-CRH test (Figs 5 and 6). Compared
2.8 g/24 h). Both urine 17-hydroxycor for the CRH test without dexametha with those who had pseudo-Cushing's
ticosteroid and free cortisol excretion sone (Figs 3 and 4). Although both states, the patients with Cushing's syn
were significantly greater in the group adrenocorticotropin and cortisol levels drome had significantly elevated corti
with Cushing's syndrome, whether or were significantly (P<.005) higher in sol (P<.001) and adrenocorticotropin
not dexamethasone was administered patients with Cushing's syndrome at all (P<.01) values at all time points, both
(P<.0001). Although the dexametha- time points, the overlap in individual before and after CRH administration.
sone-suppressed values ofboth urine 17- values was too great to afford diagnos The criterion of a basal plasma cor
hydroxycorticosteroid and free cortisol tic utility at any single point. The best tisol level greater than 38 nmol/L (1.4
excretion were significantly lower in pa criterion with 100% specificity using g/dL) during the dexamethasone-CRH
tients with pseudo-Cushing's states adrenocorticotropin was a value great test had 100% specificity, 90% sensitiv
(P<.001), there was a large overlap in er than 35 pmol/L at any time point ity, and 91% diagnostic accuracy (Table

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 10000- 10000-3-
Criterion >3450 nmol/L Criterion >38 nmol/L
64% 100% Sensitivity
Sensitivity 100% Specificity
100% Specificity

s.
76% Diagnostic Accuracy 1000 100% Diagnostic Accuracy
100% Positive Predictive Value 100% Positive Predictive value
58% Negative Predictive Value 100% Negative Predictive Value

100

10l

1000
Cushing's Pseudo-Cushing's Cushing's Pseudo-Cushing's
Syndrome States Syndrome States

Fig 4.Criteria with the best diagnostic accuracy for corticotropin-releasing hor Fig 5.Criteria for best-diagnostic accuracy for dexamethasone-corticotropin-
mone (CRH) test sum of post-CRH plasma cortisol levels. Definition of symbols releasing hormone (CRH) test; plasma cortisol levels obtained 15 minutes af
as in Fig 1. Horizontal rule indicates criterion level. ter administration of CRH. Definition of symbols as in Fig 1. Horizontal rule in
dicates criterion level.

2). After administration of CRH, those
patients with Cushing's disease whose
cortisol levels were less than 38 nmol/L
had increases in cortisol level, whereas
those with pseudo-Cushing's states gen
erally did not. A single plasma cortisol
level greater than 38 nmol/L, determined
15 minutes after administration of CRH,
separated all cases of Cushing's syn
drome from all cases of pseudo-Cush
ing's states and yielded 100% sensitiv
ity, specificity, and diagnostic accuracy
(Fig 5). The 15-minute, post-CRH cor
tisol value had significantly greater di
agnostic accuracy than the dexametha
sone-CRH basal cortisol before CRH
administration (P<.05). At time points
more than 15 minutes after administra
tion of CRH, cortisol values exceeded
38 nmol/L in some patients with pseudo-
Cushing's states and overlapped with
the responses seen in Cushing's syn
drome. However, excellent discrimina
tion was still found for the 30- and 45-
minute cortisol samples (99% and 98%
diagnostic accuracy, respectively). The
highest cortisol level recorded for any
patient in the pseudo-Cushing's group
during the dexamethasone-CRH test was
96 nmol/L (3.5 g/dL) at 60 minutes.
For the adrenocorticotropin levels
during the dexamethasone-CRH test, a
plasma adrenocorticotropin level that ex
ceeded 3.5 pmol/L at 30 minutes after
CRH administration offered the high
est diagnostic accuracy (83%) and had
74% sensitivity and 100% specificity (Ta
ble 2). The plasma adrenocorticotropin
value during the dexamethasone-CRH
test was also examined when patients
with adrenal causes of Cushing's syn
drome were excluded (because their
adrenocorticotropin values are expect
ed to be very low). Under these condi
tions, a dexamethasone-CRH plasma
adrenocorticotropin level greater than
3.83 pmol/L obtained 30 minutes after
administration of CRH had 89% diag-
nostic accuracy, 83% sensitivity, and
100% specificity. Thus, regardless of
whether patients with adrenal disease
were excluded, the dexamethasone-
CRH test, 15-minute cortisol criterion
had significantly greater sensitivity, neg
ative predictive value, and diagnostic
accuracy when compared with the best
dexamethasone-CRH adrenocorticotro
pin criterion (P<.01).
Test Comparison
Criteria with 100% specificity and
maximal sensitivity were used to com
pare the tests (Table 2). The cortisol
value of the dexamethasone-CRH test
obtained 15 minutes after CRH admin
istration had significantly greater sen
sitivity, negative predictive value, and
diagnostic accuracy when compared ei
ther to the low-dose dexamethasone test
(P<.01) or to the CRH stimulation test
performed without dexamethasone ad
ministration (P<.01).
COMMENT
The dexamethasone-CRH test, a new
test for the differential diagnosis of hy
percortisolism, distinguished patients
with mild Cushing's syndrome from
those with pseudo-Cushing's states with
greater accuracy than was possible us
ing either the low-dose dexamethasone
test or the CRH test alone. The im
provement in diagnostic accuracy of the
combined dexamethasone-CRH test
may be explicable by the pathophysiol-
ogy of Cushing's syndrome. Patients
with primary adrenal pathology and
most patients with the syndrome of ec
topie adrenocorticotropin generally show
little feedback regulation of cortisol pro
duction by glucocorticoid and little re
sponse to CRH.19 These patients are dis
criminated from patients with pseudo-
Cushing's states by virtue of their lack
of cortisol suppression by low-dose dex
amethasone.
In contrast to patients with cortisol-
producing adrenal disorders or patients
with ectopie adrenocorticotropin-produc-
ing tumors, most individuals with Cush
ing's disease show some suppression of
adrenocorticotropin and cortisol by dex
amethasone and stimulation of adreno
corticotropin and cortisol by CRH.
However, cortisol production decreases
greatly in some patients with Cushing's
disease during low-dose dexamethasone
administration, possibly because of di
minished dexamethasone clearance.2829
Such patients would be misclassified as
having pseudo-Cushing's states if eval
uated only by suppression of cortisol
production after low-dose dexametha
sone administration. Thus, the dexa
methasone-CRH test basal plasma cor
tisol measurement greater than 38
nmol/L correctly identified only 91% of
the patients in this series. By the addi
tion ofCRH to stimulate greater adreno
corticotropin and cortisol secretion (ei
ther by pituitary or adrenal30 mecha
nisms) in patients with Cushing's dis
ease who are CRH-sensitive, those
patients with unusual sensitivity to
dexamethasone suppression achieved
adrenocorticotropin and cortisol levels
above those of patients with pseudo-
Cushing's states. Thus, the dexametha
sone-CRH test, 15-minute cortisol test
correctly identified more of the patients
with Cushing's syndrome than the dex
amethasone-CRH test basal plasma cor
tisol, or the low-dose dexamethasone
suppression test, either in our series or
in others.918 Administration of CRH fol
lowing dexamethasone suppression al
lowed the criterion for the diagnosis of
Cushing's syndrome to be 100% specific
with a much higher sensitivity than was
possible with the dexamethasone test
alone (100% vs 71%, respectively).
The dexamethasone-CRH test should
be reserved for those patients who the
clinician suspects have Cushing's syn-

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O 10 20 30 40 50 60
0 10 20 30 40 50 60
Time, min
Fig 6.Results of dexamethasone-corticotropin-
releasing hormone test, following low-dose (2 mg/
d) dexamethasone pretreatment. Top, Plasma
adrenocorticotropin values. The data for pseudo-
Cushing's states and for primary adrenal disease
are superimposed. Bottom, Plasma cortisol values.
Means and SEMs are given. Definition of symbols
as in Fig 1.
drome who are found to fail to suppress
8 AM plasma cortisol after 1 mg of dex
amethasone has been administered at
11 PM, or who have an elevated 24-hour
excretion of free cortisol. After 2 days of
low-dose dexamethasone suppression, a
single plasma cortisol level obtained 15
minutes after CRH stimulation may suf
fice to discriminate patients with mild
Cushing's syndrome from those with
pseudo-Cushing's states. Individuals
with an elevated dexamethasone-CRH
plasma cortisol level could then be se
lected for further evaluation of Cush
ing's syndrome. Plasma cortisol offers
several practical advantages over the
classic response measure used in the
low-dose dexamethasone suppression
test, urine 17-hydroxycorticosteroid ex
cretion. The problems of patient adher
ence are diminished when 24-hour urine
collections are not required. Further
more, the radioimmunoassay for plasma
cortisol is easier to perform, more re
producible, more readily available, and
less expensive than urine 17-hydroxy
corticosteroid measurement. These fac
tors, combined with its excellent diag
nostic accuracy, make the dexametha
sone-CRH test a better diagnostic test
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for the presence or absence of Cushing's
syndrome.
The dexamethasone-CRH test also
compares favorably with the insulin tol
erance test as a method to distinguish
those with and without Cushing's syn
drome. Patients with Cushing's syn
drome often show little elevation in plas
ma cortisol after insulin-induced hy-
poglycemia, while those with pseudo-
Cushing's states are said to elevate
plasma cortisol normally. However, the
insulin tolerance test fails to identify
as many as 18% of patients with Cush
ing's syndrome (diagnostic accuracy
<76%),9103132 because they may show
normal responsiveness to hypoglycemia.
Thus, the dexamethasone-CRH test ap
pears to be superior to previously de
scribed tests for the differential diag
nosis of hypercortisolism.
Because individuals with mild Cush
ing's syndrome may not develop overt
signs of Cushing's syndrome for many
years, it is conceivable that some of the
patients found to have a pseudo-Cush
ing's state by our evaluation and by the
dexamethasone-CRH test might subse
quently develop apparent Cushing's syn
drome. To assess theoretically the po
tential impact of progression to Cush
ing's syndrome in some ofthese patients,
we reexamined the five patients diag
nosed with a pseudo-Cushing's state who
had the highest levels of 17-hydroxy
corticosteroid excretion during the low-
dose dexamethasone test. These five pa
tients had values greater than 11 /d
and, thus, would be classified as having
Cushing's syndrome by the classic cri
terion for this test. Two of these indi
viduals have been followed for more than
4 years without development of the signs
of Cushing's syndrome and probably do
not have the disorder. The remaining
three patients could conceivably repre
sent incorrect diagnoses. According to
this theoretical analysis, the dexametha
sone-CRH test, 15-minute cortisol level
greater than 38 nmol/L would have 100%
specificity, 95% sensitivity, and 95% di
agnostic accuracy; the low-dose dexa
methasone test would have 87% speci
ficity, 71% sensitivity, and 76% diag
nostic accuracy for the diagnosis of
Cushing's syndrome. Thus, even in the
circumstance of eventual progression to
Cushing's disease in some of the patients
diagnosed with pseudo-Cushing's states,
the dexamethasone-CRH test would re
main superior to the low-dose dexa
methasone suppression test.
The patients with pseudo-Cushing's
states in this study did not include in
dividuals with severe melancholic de
pression, anorexia nervosa, cortisol re
sistance syndrome, renal failure, or re
cent surgery. Therefore, we cannot com-
ment on whether the criteria presented
will be useful for differentiating such
patients from those with Cushing's syn
drome. Patients who have appetite dis
turbances and weight loss (as observed
in those with vegetative signs of de
pression or anorexia nervosa) typically
show resolution of hypercortisolism
when they regain weight.8 Because of
this distinction, they are not often con
fused with patients who may have Cush
ing's syndrome. However, several of our
patients, both with pseudo-Cushing's
states and Cushing's syndrome, met Di
agnostic and Statistical Manual ofMen
tal Disorders, Revised Third Edition24
criteria for affective disorder. Thus, we
believe that the dexamethasone-CRH
test may prove especially useful in the
evaluation of patients with affective dys
function and equivocal physical or bio
chemical findings.
Like all tests for the differential diag
nosis of hypercortisolism, the utility of
the dexamethasone-CRH test has been
examined only in patients who were ac
tively producing excessive cortisol. Thus,
its value in classifying those who are not
hypercortisolemic at the time of testing,
but who are believed to have Cushing's
syndrome with periodic hormonogene-
sis,33 remains unknown. Repeated 24-hour
urine collections must be performed in
such individuals to document hypercor
tisolism. Other known limitations of the
uses of dexamethasone pertain. For ex
ample, results from the dexamethasone-
CRH test should be interpreted with cau
tion in patients receiving medications that
affect the metabolism or clearance of dex
amethasone or cortisol-binding globulin.
Another limitation of this test is that it
has been studied only in adults. It is like
ly that a weight-adjusted dose of dex
amethasone (eg, 5 to 7.5 g/kg per dose17)
will be necessary for the test to be ap
plicable to children.
Previous limited studies have pro
posed the use of plasma cortisol mea
surements after dexamethasone admin
istration for the differential diagnosis of
hypercortisolism.91034-36 As in the present
study, most have shown some overlap in
the responses of those with and without
Cushing's syndrome. Although others
have performed CRH tests in clinically
normal controls and in patients with
Cushing's syndrome or depression fol
lowing a variety of dexamethasone ad
ministration regimens to demonstrate
the increased resistance to glucocorti-
coid suppression of patients with Cush
ing's syndrome,37"41 none has used dex
amethasone doses capable of inhibiting
the normal corticotroph's ability to se
crete adrenocorticotropin and compared
the results in patients with Cushing's
syndrome and in patients with pseudo-
 Cushing's states. Thus, the dexametha
sone-CRH test described in this article
is a novel test for the differential diag
nosis of hypercortisolism.
In our series, the dexamethasone-
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