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Cortisol suppression, normal baseline ACTH
10%
35/361
Cortisol suppression, high baseline ACTH
56%
203/361
No cortisol suppression, high baseline ACTH
16%
57/361
No cortisol suppression, low baseline ACTH
6%
22/361
Elevation of cortisol above pre-test levels, high baseline ACTH
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The patient in this scenario has symptoms of Cushing disease. In the setting of high baseline ACTH, suppression of cortisol with a high dose of dexamethasone indicates pituitary adenoma as the cause of disease. The most common cause of Cushing syndrome is the administration of exogenous steroids (iatrogenic Cushing). Several endogenous processes can also produce Cushing syndrome, including pituitary adenoma (Cushing disease, 70% of endogenous cases), adrenal adenoma (15% of case), and ectopic ACTH production (15% of cases). To distinguish between a pituitary adenoma that produces ACTH and an ectopic carcinoma producing ACTH, a dexamethasone suppression test is completed. Incorrect Answers: Answer 1: Cortisol suppression after dexamethasone administration amid normal baseline ACTH levels is a normal finding in patients without Cushing syndrome. Answer 3: A lack of cortisol suppression after dexamethasone administration amid high baseline ACTH levels indicates an ectopic ACTH-producing tumor. Examples include small cell lung cancer and bronchial carcinoids. Answer 4: A lack of cortisol suppression after dexamethasone administration amid low baseline ACTH levels is diagnostic of a cortisol-producing tumor, such as an adrenal adenoma. Answer 5: Dexamethasone administration does not increase serum cortisol above pre-test values.
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