Saturday, July 25, 2009

Cushing's or Syndrome X?

Q. I am a third-year medical student doing a rotation in endocrinology. A patient I saw recently has type 2 diabetes, absence of menses, high cholesterol, hypothyroid, hypertension and obesity (especially in the upper body). She was tested for Cushing's, which showed a slightly elevated level of cortisol, but it was within normal range. Is it possible to have Cushing's if the level is still within normal range? What are other indicators of this disease? Are there other diagnoses to consider?

 

A.There are two parts to the diagnosis of Cushing's syndrome: an increased cortisol production and a failure to suppress endogenous cortisol secretion when dexamethasone is administered. Indicators appear in the physical examination (muscle weakness, cutaneous striae, bruising, moon facies, buffalo hump, truncal obesity) and the lab (osteoporosis, hypokalemia, hypochloremia, metabolic alkalosis). Since your patient has a normal cortisol level, however, Cushing's would be extremely unlikely.

Whenever you are confronted with a patient with multiple problems, it is nice to find a single diagnosis to explain all the findings. This will not usually happen, though. In this case many possible combinations of diseases might be suggested. For example, the diabetes, hypercholesterolemia, hypertension and obesity mean the patient might have Syndrome X. Also, hypothyroidism is often associated with amenorrhea. So it may be the patient has two problems (hypothyroidism and Syndrome X) instead of one (Cushing's). As you can see, there are many other possible combinations.

 

From http://www.myfreedoctor.com/faq/other/614/cushings-or-syndrome-x/

3 comments:

  1. Mary,
    Could you find any place to leave a comment there? I'm thinking someone is being taught wrong. Whether the patient has Cushing's, I don't know, but I don't think it should be dismissed so easily.

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  2. Ugh! Yeah, what horrible advice! Here's what's most interesting to me: the med student said the patient's cortisol was slighly elevated *and* within the normal range. Well, which was it?!? Or does he/she mean that it was at the very high end of normal range? Either way, but especially if it was "out of range" (even if only a bit) a further workup seems warrented, especially if the patient suspects she has cushing's and feels like her obesity is unwarrented (i.e. she is overweight despite healthy eating and exercise) and/or gained the weight really suddenly. It drives me crazy when I hear about a doctor who dismisses cushing's based on *one* normal cortisol reading. I hope this patient fights for the testing she deserves!

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  3. Judy, I couldn't find a place to comment. It's too bad - I'm sure that there would be a lot.

    Maybe that site is really run by doctors and they are so SURE they're right that they don't want any comments from anyone.

    I hope so, too, Saber. Patients really have to fight this kind of thinking when they know their own bodies, know how things are supposed to be.

    Best of luck to both of you!

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