Endocrine Abstracts

Because of quite variable clinical manifestations of Cushing’s syndrome and overlap with more common medical problems, its diagnosis is frequently mistaken, with consequent considerable delay from the first presentation to a different primary and secondary care physicians to a final diagnosis, often made by endocrinologist. The diagnostic latency in reported studies vary from six months to ten years. We report a case of a 54-years-old female admitted to the hospital through the emergency department because of prominent stiffness and persistent, sharp pain in lumbal spine and bilateral hip region, extreme fatigue, muscle weakness, easy bruising and poorly controlled hypertension. Also, she noticed weight gain and hirsutism. Because of mentioned disturbances present over the last three years, she had seen multiple specialists including cardiologist, neurologist and physiatrist but no further diagnostic procedures were recommended. Family history was strongly positive for cancer. On examination, she was plethoric, overweight (BMI 27.3 kg/m²) with bruises in right gluteal region and both upper and lower extremities, proximal myopathy and blood pressure of 150/95 mmHg. Laboratory findings revealed sideropenic anemia (hemoglobin 82.8 g/l), blood glucose 5.77 mmol/l, hemoglobin A1c 5.39 %, normal electrolyte status and parameters of liver and kidney function. Hormonal examination showed ACTH of 1.3 pmol/l, morning cortisol 436.6 nmol/l with loss of diurnal variation, urinary free cortisol 303.6 nmol/l (12–486 nmol/l). Catecholamines, thyroid hormones, androgens, calcitonin and PTH were all in reference range; gonadotropins within menopausal levels. No significant supression of serum cortisol was achived after low-dose and high-dose dexamethasone supression tests (cortisol 582.9 nmol/l and 501.8 nmol/l respectively). A contrast-enhanced computed tomography and magnetic resonance imaging (MRI) of the abdomen demonstrated a 30 mm well-defined solid mass in the region of right adrenal gland. The diagnosis of Cushing syndrome was established and the patient underwent laparoscopic right adrenalectomy with patohistological finding of adrenal cortical adenoma. Based on postoperative hypocorticism and maintenance of subnormal cortisol levels, a substitution with Hydrocortison is initiated and continued in full replacement dose. Since the prevalence of Cushing’s syndrome is increasing, raised clinical awareness among primary and secondary care physicians could lead to early referral of selected patients and timelier diagnosis with reduced rate of complications.