Endocrine Abstracts

We presenting a case of 26 old lady who is known to have Denys-Drash syndrome, epilepsy and bronchial asthma who presented with history of recent significant weight gain, extensive abdominal bruising and significant muscle weakness which she described literally as not able to use her upper limbs to move to help shuffle her bottom in the floor, a manoeuvre that she was able to do before. Patient is on Carbamazepine, sodium valporate, levetiracetam , salbutamol and Pulmicort inhalers (budesonide), Laxido,And Midazolam. On examination patient was normotensive, a degree of the abdominal striate, proximal muscle weakness could not be elicited clinically. The general practitioner enquired whither the patient presentation could be a manifestation of Cushing syndrome,in this pateint the modality of investigation need to be selected carefully, patient is already on Carbamazepine which could affect both UFC and plasma cortisol as it is interferes of the chromatographic methods and can also induce hepatic clearenece of Dexamethasone, so salivary cortisol was chosen for this test, but the result showed significant high cortisol level in many different occasions (see table below), after further questioning it appears that the patient was using the Pulmicort inhaler before having the test,this lead to the significant high cortisol found.

Discussion: Salivary cortisol measurement is well established method to measure plasma free cortisol concentration, aiding the diagnosis of cortisol excess and deficiency state,it had the advantage of being free from the interference of physiological or pathological effect of CBG /albumin, ease of sampling, and lack of the stress of venepuncture. The required standered is to obtain the salivary sample using collection of passive drooling saliva or asking patient to chew a cotton pledget – (Salivette^®). Salivary samples should not be collected within 30 min of brushing teeth, drinking. No ingestion of any foods of animal origin within 3 h prior collection. Any sample with blood contamination should be discarded, smoking affect salivary 11beta-hydroxysteroid dehydrogenase type 2, this increases salivary cortisol so it should be avoided on the day of the test. The potential steroid contamination of the sample including topical or inhaled steroid is something we need to be careful with when interpreting the salivary cortisol result this was clearly missed in this case.