Differential Diagnosis
The patient's presentation of hypertension, low hemoglobin, elevated late night salivary cortisol levels, and osteoporosis suggests an endocrine disorder. Here's a categorized differential diagnosis:
- Single most likely diagnosis
- Cushing's syndrome: The elevated late night salivary cortisol levels and the presence of hypertension, osteoporosis, and proximal muscle wasting are consistent with Cushing's syndrome. The elevated adrenocorticotropic hormone (ACTH) level suggests an ACTH-dependent cause, such as a pituitary adenoma.
- Other Likely diagnoses
- Primary aldosteronism: Although less likely, primary aldosteronism could explain the hypertension and osteoporosis. However, the elevated cortisol levels and ACTH level make this diagnosis less probable.
- Hyperparathyroidism: This condition could contribute to the osteoporosis and elevated blood pressure, but it does not fully explain the patient's presentation, particularly the elevated cortisol levels.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Pheochromocytoma: Although rare, pheochromocytoma can cause hypertension and could be deadly if missed. However, the patient's presentation does not strongly suggest this diagnosis.
- Adrenal carcinoma: This rare tumor can produce excess cortisol and/or aldosterone, leading to Cushing's syndrome or primary aldosteronism. It is essential to consider this diagnosis due to its potential severity.
- Rare diagnoses
- Familial Cushing's syndrome: This rare genetic disorder can cause Cushing's syndrome, but it is less likely given the patient's age and lack of family history.
- Ectopic ACTH-producing tumor: This rare condition can cause Cushing's syndrome, but it is often associated with other symptoms, such as weight loss and skin changes, which are not mentioned in the patient's presentation.