What is the best course of action for a 37-year-old woman with persistent anxiety, significant unintentional weight loss, paresthesias, and cognitive impairment, who has undergone extensive negative workup, including normal thyroid studies, vitamin B12 (385 pg/mL), pheochromocytoma and celiac screens, complete blood count (CBC), metabolic panel, antinuclear antibody (ANA) test, and computed tomography (CT) of the abdomen and pelvis, with mild inflammatory markers, elevated morning cortisol (29 mcg/dL) and normal adrenocorticotropic hormone (ACTH) levels, and a history of treatment with fluoxetine (Prozac), escitalopram (Lexapro), divalproex (Depakote), buspirone (Buspar), and dextroamphetamine-amphetamine (Adderall), and recently lybalvi?

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Immediate Workup for ACTH-Dependent Cushing Syndrome

This patient requires immediate 24-hour urinary free cortisol collection to confirm true hypercortisolism, followed by pituitary MRI and likely bilateral inferior petrosal sinus sampling (BIPSS), as the combination of elevated cortisol (29 mcg/dL) with normal (detectable) ACTH definitively indicates ACTH-dependent Cushing syndrome—not a primary psychiatric disorder. 1

Why This Is ACTH-Dependent Cushing Syndrome

The biochemical pattern is diagnostic:

  • Elevated morning cortisol with detectable/normal ACTH rules out primary adrenal causes (which would suppress ACTH to undetectable levels) and confirms ACTH-dependent hypercortisolism 1, 2
  • Normal ACTH in the setting of hypercortisolism indicates either pituitary adenoma (Cushing disease) or ectopic ACTH production from tumors in lung, thyroid, pancreas, or bowel 1, 2

Clinical Presentation Matches Cushing Syndrome

Her symptoms are entirely consistent with hypercortisolism, not primary psychiatric disease:

  • Significant unintentional weight loss occurs in 20% of Cushing syndrome patients despite classic teaching of weight gain 1
  • Persistent anxiety and cognitive impairment are direct manifestations of hypercortisolism, not treatment-refractory psychiatric illness 1
  • Paresthesias may represent hypercortisolism-induced proximal muscle weakness and myopathy 1
  • Impaired fasting glucose (116 mg/dL) and mild inflammatory markers (ESR 29, CRP 15) are consistent with hypercortisolism-induced hyperglycemia and inflammation 1

Algorithmic Diagnostic Workup

Step 1: Confirm True Hypercortisolism

  • Obtain 24-hour urinary free cortisol immediately to distinguish true hypercortisolism from stress-related elevation 1, 2

Step 2: Localize ACTH Source

  • Order pituitary MRI with sellar cuts protocol as the first imaging study (sensitivity 63% for detecting pituitary adenomas) 1, 2
  • If MRI is negative or equivocal, proceed directly to BIPSS, which is the gold standard with 95% diagnostic accuracy 1, 2
  • Central-to-peripheral ACTH ratio ≥2:1 before CRH/desmopressin and ≥3:1 after stimulation confirms pituitary Cushing disease 1, 2

Step 3: If Ectopic Source Suspected

  • Obtain chest/abdominal/pelvic CT or whole-body PET/CT to locate ectopic tumors (detection rate 80%) 1, 2

Treatment Based on Source

For Pituitary Cushing Disease (Most Likely)

  • Transsphenoidal surgical resection is first-line treatment when adenoma is identified (80% success rate) 1, 2
  • Postoperative corticosteroid supplementation is mandatory until HPA axis recovery 1, 2
  • Ketoconazole 400-1200 mg/day is preferred medical therapy if surgery is delayed or unsuccessful (70% response rate, relatively tolerable side effects) 1, 2

For Ectopic ACTH Production

  • Surgical removal of ectopic tumor if possible 2
  • Bilateral laparoscopic adrenalectomy if tumor is unresectable 2
  • Medical management with ketoconazole or mitotane 2

Critical Monitoring During Workup

  • Screen for hypertension, hypokalemia, and hyperglycemia (present in 50% of cases) 1
  • Monitor for adrenal crisis risk during BIPSS procedure (10% risk) 1
  • Follow-up imaging and biomarkers every 3-6 months if treatment is delayed 1, 2
  • Consider supplementing B12 to >400 pg/mL (current level 385 pg/mL) to address potential contribution to paresthesias (50% response rate) 1

Critical Pitfalls to Avoid

  • Do not attribute symptoms to primary psychiatric disease when objective evidence of hypercortisolism exists (causes 6-month diagnostic delay) 1
  • Do not rely solely on pituitary MRI, as 37% of pituitary adenomas are not visible on imaging, requiring BIPSS for diagnosis 1
  • Do not delay workup for "psychiatric stabilization", as untreated Cushing syndrome causes progressive morbidity with 10% mortality 1
  • Do not confuse pseudo-Cushing states (depression, alcoholism, obesity) with true Cushing syndrome (20% misdiagnosis rate) 1, 2

Regarding Her Psychiatric Medications

Her persistent anxiety despite multiple SSRI trials (Prozac, Lexapro) and adjunctive agents (Depakote, Buspar, Adderall, Lybalvi) strongly suggests that the anxiety is a manifestation of untreated hypercortisolism, not treatment-refractory psychiatric illness 1. The cognitive impairment following polypharmacy discontinuation likely represents unmasking of cortisol-induced cognitive dysfunction rather than medication withdrawal effects.

References

Guideline

Diagnostic Approach to ACTH-Dependent Hypercortisolism

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Guideline

Diagnosis and Treatment for Elevated Cortisol with Non-Suppressed ACTH

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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