Endocrine Abstracts

Introduction: Cushing syndrome could be missed initially, especially when the presenting features are common in the general population. Before proceeding to the hormonal tests we have to consider that recent studies have shown that up to 50% of patients with CD have different degrees of altered glucose metabolism, up to 80% of CS patients have hypertension independently of their age and sex and hypercorticism changes bone structure and causes vertebral fractures in approximately 70% percent of patients.

Aim: To present a patient with ACTH dependent Cushing syndrome with many complications of Cushing disease but no specific clinical signs.

Patient and methods: A 68 year old obese woman (BMI = 30.4 kg/m²), known with hypertension, osteoporosis, multinodular goiter presented in 2019 for endocrine assessment and was diagnosed with diabetes mellitus and ACTH dependent Cushing syndrome.

Case report: Physical examination showed central obesity, without facial plethora, without easy bruising, without reddish purple striae, with minimal hirsutism on the upper lip, BP = 140/85 mm Hg despite treatment with 4 antihypertensive drugs. Visual field was normal. Thyroid examination detected a dominant nodule in a multinodular gland, about 4 cm in size (TIRADS 4, BETHESDA 2). Diabetes mellitus was diagnosed and there was no improvement in bone mineral density (BMD) after 2 years of antiresorbtive therapy (Lumbar BMD 2018–0.791 g/cm², lumbar BMD 2019–0.767 g/cm²). Laboratory tests revealed increased basal serum 0800 h cortisol (28.62 µg/dl) and plasmatic ACTH (137.3 pg/ml), increased serum 2300 h cortisol (13.56 µg/dl), unsuppressed 8 A.M serum cortisol after 1 mg dexamethasone overnight test (27 µg/dl ) and after two-day, low-dose dexamethasone suppression test (6 mg/dl).The tests suggested ACTH dependent Cushing syndrome. CT scan showed a pituitary macroadenoma and unilateral adrenal hyperplasia. NET markers (5 HIA, serotonin) were normal, apart Cromogranin A which was mild elevated but the patient was taking proton pump inhibitors. Metanephrines and normetanephrines were normal. There were no pulmonary nodules on chest X-Ray scan. Therefore, Cushing disease was suspected. Pituitary surgery is pending.

Conclusion: Simultaneous development and increasing severity of Cushing Syndrome complications such as diabetes, osteoporosis, hypertension in older patient, it’s a clinical clue that should trigger the screening, despite the fact that this disease is often diagnosed at younger ages (25 to 45 years).