PHYSIOLOGY LABORATORY

ENDOCRINE PHYSIOLOGY CASE

Case scenario:

Harold Potts is a 48-year-old employee of a local moving company. Over the past 2 years, he had gained
30 pounds, mostly around his “middle,” face, and shoulders, although his arms and legs had become very
thin. In addition, he had purple stretch marks on his abdomen. His appetite had always been good, but in
the past 2 years, it had become enormous! He made an appointment to see his physician because he was
having trouble doing the heavy lifting that is required in his job.

In the physician’s office, Harold’s blood pressure was significantly elevated at 165/105. He had centripetal
(truncal) obesity with thin extremities, a buffalo hump (interscapular fat accumulation), a “moon” face,
and purple stretch marks (striae) on his abdomen. Below summarizes the laboratory results obtained in
the fasting state.

Harold’s Laboratory Values

Serum Na+ 140 mEq/L (normal, 140 mEq/L)

Serum K+ 3.0 mEq/L (normal, 4.5 mEq/L)

Fasting glucose 155 mg/dL (normal, 70–110 mg/dL)

Serum cortisol Increased

Serum ACTH Undetectable

When a low dose of dexamethasone (a synthetic glucocorticoid) was administered, Harold’s serum
cortisol level remained elevated. Harold’s physician ordered a computed tomography scan, which showed
a 7-cm mass (adenoma) on the right adrenal gland. The adenoma was surgically removed 1 week later.

Questions:

1. Where in the adrenal cortex is cortisol produced?

2. How do glucocorticoids inhibit prostaglandin production?

3. Harold had Cushing’s syndrome. He had an adrenal adenoma that secreted large amounts of
adrenocortical hormones, primarily cortisol and aldosterone. The increased levels of cortisol were
responsible for Harold’s centripetal obesity, buffalo hump, muscle wasting, striae, and hyperglycemia
(increased blood glucose concentration). How is each of these abnormalities caused by increased
circulating levels of cortisol?

4. Why was Harold’s serum adrenocorticotropic hormone (ACTH) level so low? Which etiologies of
hypercortisolism were ruled out by his decreased serum ACTH level?

5. How would a healthy person respond to a low-dose dexamethasone test? Was Harold’s response
normal? If not, why not?
6. Why was Harold’s Pa increased?

7. Why was Harold’s serum K+ concentration decreased?

8. In women, Cushing’s syndrome causes masculinization, with increased body hair, acne, and irregular
menses. Why does Cushing’s syndrome have these effects in women?

9. If Harold’s surgery had been delayed, his physician could have prescribed a drug that inhibits the
synthesis of adrenocortical steroids. What drug might he have prescribed, and what is its mechanism of
action?

10. Why is hyperpigmentation not found in patients with secondary adrenocortical insufficiency?