A 66-year-old woman is brought to the emergency department due to agitation, restlessness, and poor sleep. Over the past 3 months, she has had headaches and gained 6.3 kg (13.9 lb). The patient's medical history is unremarkable, and she takes no medications. She has smoked a pack of cigarettes daily for the last 50 years but does not use illicit drugs. Blood pressure is 160/110 mm Hg and pulse is 90/min. Skin examination shows facial plethora and scattered bruises on her extremities. Laboratory results are as follows: Which of the following is the most likely cause of this patient's hypertension?

Question

A 66-year-old woman is brought to the emergency department due to agitation, restlessness, and poor sleep.  Over the past 3 months, she has had headaches and gained 6.3 kg (13.9 lb).  The patient's medical history is unremarkable, and she takes no medications.  She has smoked a pack of cigarettes daily for the last 50 years but does not use illicit drugs.  Blood pressure is 160/110 mm Hg and pulse is 90/min.  Skin examination shows facial plethora and scattered bruises on her extremities.  Laboratory results are as follows:  Which of the following is the most likely cause of this patient's hypertension?

Quizplus · Accepted Answer

11ec25c8_d3a2_7936_bc81_1722507d6334_MD0003_00 This patient's hypertension, neuropsychiatric disturbances, hyperglycemia, and weight gain suggest hypercortisolism (Cushing syndrome). Other manifestations can include proximal muscle weakness, central adiposity with enlargement of the supraclavicular and dorsal neck fat pads, abdominal stria, facial rounding, and ecchymosis. Most cases of Cushing syndrome are due to exogenous glucocorticoid intake, ectopic ACTH production (eg, small cell lung cancer), or ACTH-producing pituitary adenomas (Cushing disease). Primary adrenal hypercortisolism (eg, adrenal adenoma) is less common. Associated hypokalemia suggests severe hypercortisolism and is most often seen with ectopic ACTH-producing tumors. manifestations stria Initial testing for suspected hypercortisolism can include a 24-hour assay for urine free cortisol, a late-night salivary cortisol measurement, or a low-dose dexamethasone suppression test. Once hypercortisolism is established, an ACTH level can determine whether it is ACTH-dependent (Cushing disease or ectopic ACTH production) or ACTH-independent (adrenal disease or exogenous glucocorticoid intake). Patients with an elevated ACTH should have a high-dose dexamethasone suppression test to determine whether ACTH production is pituitary (dexamethasone suppresses cortisol production) or ectopic (dexamethasone does not suppress cortisol). (Choice A) Pheochromocytoma is a catecholamine-producing adrenal medullary tumor. (Extra-adrenal tumors are termed paragangliomas). In addition to severe hypertension, associated symptoms can include weight loss, tachycardia, diaphoresis, and anxiety. (Choice B) Aortic dissection causes severe chest pain radiating to the back. Although it occurs most commonly in patients with hypertension, this patient has no other features of aortic dissection. (Choice D) Hypothyroidism can cause hypertension due to increased norepinephrine and aldosterone levels, leading to increased systemic vascular resistance. However, other expected findings would include fatigue, bradycardia, depression, and skin and hair changes. (Choice E) Hyperparathyroidism typically presents with asymptomatic hypercalcemia. Hyperparathyroidism can cause elevated blood pressure, but this patient's normal serum calcium makes this less likely. (Choice F) Renal artery stenosis (RAS) can cause severe hypertension often associated with flash pulmonary edema, resistant heart failure, and chronic kidney disease. Patients may also have an abdominal bruit. RAS is usually seen in patients with other features of atherosclerosis. (Choice G) Renal parenchymal disease with decreased glomerular filtration rate can cause resistant hypertension, but this patient's normal blood urea nitrogen and creatinine rule out significant renal disease. Educational objective: Cushing syndrome is characterized by hypertension, hyperglycemia, and weight gain. Common causes include excess glucocorticoid intake, ACTH-producing pituitary adenoma, and ectopic ACTH production. References: The diagnosis of Cushing's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/20821267)

A 66-Year-Old Woman Is Brought to the Emergency Department Due