Cushing'S Syndrome and Hypoadrenalism Diagnosis
Cushing'S Syndrome and Hypoadrenalism Diagnosis
Cushing'S Syndrome and Hypoadrenalism Diagnosis
Screening tests: 1.Circadian rhythm of plasma cortisol 2.Late-night salivary cortisol (2 measurements) 3.Urinary free cortisol (2 measurements) 4.The overnight 1-mg dexamethasone suppression tests (DST) 5.The 2-day 2 mg dexamethasone test
Tests
1. 2. 3. 4. 5. 6. 7. 8. ACTH level Plasma potassium, bicarbonate High-dose DXM suppression test CRH test Inferior petrosal sinus sampling CT, MRI pituitary, adrenal Scintigraphy Tumor markers
1. ACTH
- Serum ACTH - IRMA - Normal range 9-52 pg/ml (2-11 pmol/l)
- A value < 5 pg/ml ACTH independent cause
2. Potassium, bicarbonate
HYPOKALEMIC ALKALOSIS
+48 hours
Cushings disease
4. CRH test
- CRH 1g/kg or 100g I.V.
- Can be performed after DXM test
- Cortisol and ACTH measurements before and every 15 minutes after, for 2 hours - Normal response ACTH and cortisol rise of 15-20% - ACTH rise > 50 % and cortisol rise > 20 % Cushings disease
6. CT/MRI pituitary
- Only after dynamic tests!
6. CT/MRI - adrenal
Massive macronodular hyperplasia. Adrenal glands are replaced by multiple nodules (arrows)
Hypoadrenalism suspected
Basal cortisol > 14.5 g/dl (400 nmol/L) intact HPA axis
1.Routine biochemical profile 2.Mineralocorticoid status 3.Hypothalamic-pituitary-adrenal axis function evaluation 4.Other tests
- Hypercalcemia
- Azotemia - Anemia - Eosinophilia
2. Mineralocorticoid status
Primary hypoadrenalism PRA, aldosterone
- Primary hypoadrenalism Exaggerated elevation of ACTH at 45 minutes - Secondary response hypoadrenalism no ACTH
4. Other tests
- Imaging testing adrenal CT - Serum antibodies against 21-hydroxylase
Bilateral metastases
Bilateral hemorrhage