Mechanism of fraud:
(1) ingestion or injection of synthetic steroids
(2) tampering with urine samples
Clinical features:
(1) history of anxiety, depression or drug abuse
(2) close contact with health care (self, friend or relative)
(3) evidence of self-injection
(4) history of factitious disease
Imaging studies:
(1) adrenal glands on imaging studies may be of normal size, small or atrophic
(2) pituitary imaging studies may be normal or show incidental microadenomas
Laboratory findings:
(1) striking variability in urine free cortisol
(2) striking variability in urine 17-hydroxysteroid (17-OHCS)
(3) discrepancy between serum and urine steroid levels (serum normal, urine very high)
(4) discrepancy between free cortisol and free corticosterone concentrations (in excess production both should be increased; in factitious disease cortisol is elevated and corticosterone is normal; in cortisol self-medication corticosterone is decreased)
(5) normal serum ACTH levels
(6) presence of synthetic glucocorticoids on HPLC analysis of urine
Differential diagnosis:
(1) accidental contamination of urine by vaginal cream containing cortisol
(2) periodic Cushing's syndrome
