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Limitations of nocturnal salivary cortisol and urine free cortisol in the diagnosis of mild Cushing's syndrome


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Limitations of nocturnal salivary cortisol and urine free cortisol in the diagnosis of mild Cushing's syndrome

 

Srividya Kidambi1,2, Hershel Raff1,2 and James W Findling1,2

1 Endocrine Research Laboratory, Endocrine-Diabetes Center, Aurora St Luke's Medical Center, Milwaukee, Wisconsin 53215, USA and 2 Division of Endocrinology,, Metabolism and Clinical Nutrition, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA

 

(Correspondence should be addressed to H Raff who is now at Endocrine Research Laboratory, St Luke's Physician's Office Building, 2801 West KK River Parkway, Suite 245, Milwaukee, Wisconsin 53215, USA; Email: hraff@mcw.edu)

 

Objective: Cushing's syndrome (CS) is difficult to diagnose due to its nonspecific presentation. Diagnostic tests like 24-h urine free cortisol (UFC) and the overnight 1 mg dexamethasone suppression test (DST) lack sufficient sensitivity and specificity. Measurement of nocturnal salivary cortisol (NSC) is an accurate and reproducible test with a high sensitivity for CS. However, its performance in mild CS has not been reported. We present 11 cases of CS with normal or mildly elevated UFC in whom NSC was helpful in making a diagnosis.

 

Design and methods: All patients had at least one collection of 24-h UFC and NSC and eight had an overnight 1 mg DST. The number of NSC measurements per patient was determined by the clinical index of suspicion and the results of initial testing. Imaging studies included magnetic resonance imaging (MRI) of pituitary or computer tomography scan of abdomen.

 

Results: Only four out of eleven patients had elevations in UFC and none were >2 times the upper limit of normal. Seven out of eight had an abnormal DST. All patients had some elevated NSCs (14?100%). Out of eleven patients, six had an abnormality in the pituitary gland found by MRI and two out of eleven had adrenal masses. The remaining three had normal pituitary MRI but had inferior petrosal sinus (IPS) sampling indicating Cushing's disease. All patients had appropriate surgery, and histopathology of all except one was suggestive of either a cortisol-producing adrenal adenoma or an ACTH-secreting pituitary adenoma.

 

Conclusion: Neither a normal UFC nor a normal NSC excludes mild CS. Multiple samples (urine/saliva) and DST are needed to make the diagnosis of mild CS.

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Jane.

 

You've been digging again...useful information.

 

Good to see you posting again...you've been missed ya' know'

 

Dave

Thanks Dave...glad to be back in the loop again myself. :spudnikwaving:

 

Jane,

 

I want to thank you for this info as well. Do you have Melissa's e-mail address, I think she would like to read this and she has been so busy, she hasn't been able to get on the boards lately.

 

Hugs,

Lorri

I sure do. I'll pop this over to her right now before I forget.

 

Interestingly, I posted this before I realized the main contact/researcher for this study was the very man I posted about last night. Seems to me we're getting a real friend in high places with Dr. Raff.

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I wonder if I should take my sister to see him (and maybe our mom)? Our parents live in Milwaukee...

He's a researcher (PhD) so I think it's doubtful he would see any patients, BUT maybe he/his department could recommend someone good to see through St. Luke's? I'd definitely contact him and see what studies might be going on and/or what doctors they regularly work with there. :(

 

 

update: I just checked the department's website and I do see doctors there that see patients have have a particular interest in pituitary and adrenal diseases including Cushing's. I think it'd be a great idea to give them a buzz for your sister and your mom!

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Great article! Thanks, Jane.

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I had gone to see Dr. Findling at one time. At the time, he did not really seem to believe strongly (if at all) of cyclical cushings.

 

I had some elavated UFCs and salivaries, but since I then had some low ones, it was ruled out. He stated there was nothing else he could do.

 

Now, perhaps with the knew knowledge the hospital has, Dr. Findling will have changed his mind.

 

It has been a few years so he may have of course, but it is something to watch out for if going to see him. The researcher does intrigue me, enough that I may contact the hospital or visit to see what their views are.

 

Anyway, if anyone finds anything out, please let us know.

 

Nick

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Oh my goodness! When I spoke with Dr. L, the 2nd time this week, he mentioned this VERY article. He had read it that morning! Thanks!

 

 

Mar

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