Cushing’s Syndrome
Patient Presentation
A 33-year-old female presents with secondary amenorrhea - the absence of her menses for over a year, hirsutism, significant weight gain of 15 kg within the past 2 months, acne, significant muscle weakness, recurrent headaches, hair loss, wine-colored striae on the abdomen and extremities, facial roundness, a lump over the back of her neck, and feelings of depression.
Diagnosis
The patient presents with symptoms indicative of Cushing’s syndrome. The patient was admitted to further continue the endocrine evaluation. Multiple tests were ordered to confirm the preliminary diagnosis of Cushing’s syndrome. The results are as follows:
A chem 7 panel was ordered and the glucose resulted in 335 mg/dL (high) and all other values were WNL. The patient’s complete blood count resulted in a white blood cell count of 11.28 K/uL (high) and all other values were WNL. The patient’s 24-hour urinary free cortisol level was 1440 mcg/24 hours (high). Her serum cortisol levels remained elevated with results of 25 mcg/dL at 2300 and 32.3 mcg/dL at 0000 with ACTH levels of 56.5 pg/mL (high) and 86.6 pg/mL (high) respectively. The following morning her cortisol levels were 29.4 mcg/dL (high) at 0730 and 34.3 mcg/dL (high) at 0800 with ACTH levels of 61.9 pg/mL (high) and 91.4 pg/mL (high), respectively. The patient then underwent a high-dose dexamethasone suppression test in which the patient’s serum cortisol level went from 21.4 mcg/dL (high) and 34.3 mcg/dL (high) to 4.8 mcg/dL the next morning. These findings were consistent with Cushing’s disease and suggestive of a pituitary adenoma. A MRI of the pituitary was obtained and showed a hypo-enhancing lesion within the pituitary, concerning for pituitary adenoma.
Diagnosis: Cushing’s disease
Treatment
The patient underwent a trans-sphenoidal hypophysectomy for resection of the pituitary adenoma.
Outcome
The patient tolerated the surgery well. Post-operatively, her cortisol levels remained less than 2mcg/dL. A 24-hour urine collection for cortisol remained undetectable. ACTH levels remained less than 5pg/mL. The patient experienced some symptoms of fatigue and slight tachycardia suggestive of adrenal insufficiency on her 4th post-operative recovery day. The patient was then started on hydrocortisone 15 mg in the morning and 5mg in the afternoon. The patient’s tachycardia resolved. She was discharged and instructed to continue her hydrocortisone therapy of 15 mg in the morning and 5 mg in the afternoon for 4 months. The hydrocortisone therapy will be evaluated and adjusted with future follow-up visits. At the first follow-up visit in the clinic, the patient stated that she lost 17 kg, was feeling more energetic, hirsutism and acne decreased, the purple-colored striae changed to a whitish color, and she began experiencing regular menstrual periods.