A 45-year-old woman calls 911 due to severe chest pain and dyspnea. The emergency medical team finds the patient unresponsive with no pulse, and she does not revive despite extensive cardiopulmonary resuscitation efforts. She had a prolonged history of systemic lupus erythematosus treated with multiple medications and was recently evaluated for progressive muscle weakness. Records from the patient's most recent office visit show an elevated blood pressure and examination findings of facial plethora, truncal obesity, and skin ecchymoses. She was also found to have mild hyperglycemia. Medical history included a left hip replacement for osteonecrosis of the femoral head 1 year ago. At autopsy, she is found to have an occluding thrombus in the left main coronary artery, which likely led to sudden cardiac death. Examination of this patient's adrenal glands is most likely to reveal which of the following findings?

Question

A 45-year-old woman calls 911 due to severe chest pain and dyspnea.  The emergency medical team finds the patient unresponsive with no pulse, and she does not revive despite extensive cardiopulmonary resuscitation efforts.  She had a prolonged history of systemic lupus erythematosus treated with multiple medications and was recently evaluated for progressive muscle weakness.  Records from the patient's most recent office visit show an elevated blood pressure and examination findings of facial plethora, truncal obesity, and skin ecchymoses.  She was also found to have mild hyperglycemia.  Medical history included a left hip replacement for osteonecrosis of the femoral head 1 year ago.  At autopsy, she is found to have an occluding thrombus in the left main coronary artery, which likely led to sudden cardiac death.  Examination of this patient's adrenal glands is most likely to reveal which of the following findings?

Quizplus · Accepted Answer

11ec160b_3ab3_6831_9249_876393307fd9_MD0001_00 This patient has features of hypercortisolism, including hypertension, central obesity, muscular weakness, ecchymoses, and hyperglycemia. She most likely developed iatrogenic Cushing syndrome due to prolonged administration of glucocorticoids for management of systemic lupus erythematosus (SLE). Chronic glucocorticoid use can also cause osteonecrosis, and both Cushing syndrome and SLE itself can increase the risk for atherosclerosis and acute coronary events (as in this patient). Exogenous glucocorticoid use inhibits the entire hypothalamic-pituitary-adrenal axis, leading to low levels of corticotropin-releasing hormone (CRH), ACTH, and endogenous cortisol. ACTH exerts a potent trophic (ie, growth promoting) effect on the adrenal zona fasciculata and reticularis; long-term suppression leads to adrenocortical atrophy (the zona glomerulosa is spared as angiotensin II is its primary trophic hormone). Sudden cessation of glucocorticoids after prolonged use can precipitate adrenocortical insufficiency and adrenal crisis. (Choice A) Endogenous Cushing syndrome can be caused by an autonomous cortisol-producing adrenal tumor. However, this patient's history is more suggestive of exogenous glucocorticoid use. (Choices C, D, and E) Bilateral cortical hyperplasia and hypertrophy occurs in patients with ACTH excess (eg, pituitary corticotroph adenoma [Cushing disease]). Varying degrees of adrenocortical nodularity can also be seen. However, this patient was likely taking exogenous glucocorticoids, which would suppress ACTH release and lead to adrenocortical atrophy. Educational objective: Long-term use of supraphysiologic doses of glucocorticoids causes suppression of the hypothalamic-pituitary-adrenal axis, which in turn leads to bilateral adrenocortical atrophy involving the zona fasciculata and reticularis. Sudden cessation of the exogenous corticosteroids can precipitate adrenal crisis. __________ References: Management issues with exogenous steroid therapy. (http://www.ncbi.nlm.nih.gov/pubmed/24910822)

A 45-Year-Old Woman Calls 911 Due to Severe Chest Pain