Endocrine Abstracts

A 37-year-old female referred by gynaecologist with elevated serum testosterone found on evaluation for amenorrhoea. She has had oligomenorrhoea for 5 years with induced bleed on Logynon and no change on stopping. Episodes of feeling hot and sweaty and going red in face. On examination: weight 68 kg, BMI 25 kg/m², euthyroid, euadrenal, no hirsutism. BP: 116/86 (lying) & 110/90 (standing for 2 min). Available blood results: Estradiol- 43–91; LH- <0.1–6.9 and FSH- 0.3–15.4; S Testosterone- 6.6 and 3.5 and 4.1 nmol/l; DHEAS- 15.9 umol/l. Others- prolactin, TSH, Vit B12, folate, HbA1c- all normal. Elevated DHEAS suggesting adrenal source. Available CT abdomen (noncontrast)- adrenals normal. TA and TV USS- ovaries small without follicles. Suspected possible premature ovarian failure! But LH and FSH not suggesting of and source of Testosterone and DHEAS still unclear. Evaluation: FBC- normal, Corr Ca²⁺2.38 mmol/l, PO_4- 0.70 mmol/l, T Chol.- 5.4 mmol/l, HDL- 1.6 mmol/l, Vit D- 84.3 nmol/l; HbA1c- 40 mmol/mol, Prolactin- 152 mU/l, TSH- 0.63 mU/L, S Cortisol- 1144 nmol/l (09:45am), Testosterone- 2.4 nmol/l, E2- 77 pmol/l, FSH- 3.1 and LH 0.1 u/l, 17OHP- 2.1 nmol/l (1.9–6.5). Tests suggesting cortisol excess and normalised testosterone. DHEAS- 15.6 umol/l (1.7–9.2). Further evaluation: 24-h urine cortisol excretion- 1127 and 368 nmol/24 h (100–379); ODST (1 mg) S Cortisol – 1317 nmol/l. LDDST (0.5 mgx8) S Cortisol- basal 1251 nmol/l and 48 h 459 nmol/l; ACTH (with basal sample)- 54 nmol/l. Tests suggests ACTH-dependent Cushings possible pituitary source. Review: bruising easily, now round face, with slight flushed appearance, small base of neck hump. Further evaluation: HDDST (2 mgx8); basal 1332 and 48 h- 1507 nmol/l; MRI pituitary- normal. Suggesting possible ectopic source of ACTH. BMD: osteoporosis in spine and osteopenia in hips. Further review: very flushed, more cushingoid in her facial appearance, weight stable, BP- 130/84. Contrast CT (neck to pelvis)- poorly enhancing rounded lesion in liver with nonspecific appearance, nil else. Where is source of ACTH and how to explain various hormonal abnormalities?