Controversy exists as to the pathophysiology in Cushing's syndrome with nodular adrenocortical hyperplasia. Of the eight patients reported by Meador et al in 1967, all showed resistance to dexamethasone suppression.1 However responses to corticotropin and metyrapone were variable, and plasma adrenocorticotropic hormone (ACTH) levels by bioassay, ranged from low to normal. Consequently, opinion has differed as to whether this condition represents a primary hypothalamic pituitary defect, primary adrenal autonomy, or a combination of both.
The patient with nodular adrenocortical hyperplasia reported here illustrates the complex combination of pituitary-adrenal control that may be present and the danger of isolated measurements of plasma ACTH concentration and dexamethasone suppression.
A 44-year-old woman entered Cincinnati General Hospital in June 1966, referred by her private physician who diagnosed possible Cushing's syndrome. She was in good health until six years prior to this admission, when she began to experience menorrhagia, hot flushes, and