Endocrine Abstracts

Diagnosis of Cushing’s syndrome is challenging in the absence of cardinal features. But still, they have the same metabolic risk due to the presence of biochemical hypercortisolism. A 35-year lady was referred to the tertiary care endocrine unit following an incidental finding of high cortisol levels while on treatment for covid in 2021. She also had some weight gain, slow healing of wounds, and easy bruising. She did not have any features of hyperandrogenism and hypertension, or diabetes. Her periods were regular. On examination, BMI was 21.4 kgm-3, and blood pressure 142/90 mmHg. There were no cushingoid facies, no dorso-cervical or supraclavicular fat deposition, no abdominal striae, no proximal muscle weakness, and no hirsutism or clitoromegaly. Investigations found to have Basal cortisol -1218nmo/l, ODST (overnight)-437 nmol/l, ODST(low dose , 48 hr)- 455 nmol/l, Mid night salivary cortisol-5.5nmol/L(<3.2nmol/l), ACTH level <5ng/l. The Dexamethasone CRH test fail to suppress cortisol levels and ACTH < 5ng/l CT scan adrenal showed a 26 mm right adrenal lesion with washout characteristics consistent with an adenoma. Normal left adrenal. Pre-contrast washout was 33HU, 60s post-contrast washout 80 HU and 15 min post-contrast washout was 35HU. Absolute washout was 96 % consistent with adenoma. The patent has successful surgery led to the resolution of hypercortisolism and symptoms. This case highlights the challenges in the diagnosis of Cushing’s in the absence of cardinal features. This problem occurs because there is an increasing global prevalence of obesity and diabetes, and the increasing use of exogenous glucocorticoids, leads to pseudo Cushings. And there is uncertainty about the best screening test for Cushing’s and how to individualize the choice of tests to prevent false positives. There is difficulty in identifying pathologic hypercortisolism in certain conditions: when it is extremely mild or cyclic. These difficulties are mitigated in part by the availability of assays for synthetic glucocorticoids, an increased understanding of the caveats and confounding factors that can cause false-positive and false-negative tests, and an increased understanding of the physiologic underpinning of pseudo-Cushings.