Case 052: Cushing’s Syndrome

PATIENT PRESENTATION

Chief Complaint

“I don’t know why I’m gaining weight and my periods have become irregular. Maybe I’m going through early menopause.”

History of Present Illness

A 46-year-old female patient presents with concerns of weight gain over the last six to 12 months despite starting an exercise regimen of brisk walking five days a week. She also complains of increased appetite, facial acne, change in mood, and irregular menses.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What signs and symptoms of Cushing’s syndrome does the patient exhibit?

   Hint: See Hypercortisolism (Cushing Syndrome) in PPP

2. What is the likely etiology of Cushing’s syndrome in this patient?

   Hint: See Table 46-4 in PPP

3. How should Cushing’s syndrome in this patient be evaluated and treated?

   Hint: See Hypercortisolism (Cushing Syndrome) in PPP

4. What patient education points should be provided regarding the Cushing’s syndrome?

   Hint: See Hypercortisolism (Cushing Syndrome) and Table 46-7 in PPP. Need to evaluate if the patient takes any nonprescription medications or herbals. Some of these may have corticosteroid activity or may be adulterated with corticosteroids.

5. What patient education points should be provided whenever a patient start a glucocorticoid prescription?

   Hint: See Adrenal Insufficiency in PPP

FOLLOW-UP

If the patient was referred to an endocrinologist for diagnostic testing, what additional questions should be asked of the patient at that time to avoid a false positive or negative test result?

Hint: See Table 46-5 in PPP

CASE SUMMARY

Global Perspective

Endogenous Cushing’s syndrome is an uncommon disorder with a higher rate in females compared to males. The estimated population prevalence is 0.7-2.4 persons per million per year.¹ A Denmark study reported that the prevalence in that country is from 1985-1995 is 2.3 persons per million per year.² A similar study analyzed the rate of newly-diagnosed Cushing’s disease in Vizcaya Spain and reported an incidence of 2.3 cases per million inhabitants per year.³ Treatment options for various types of endogenous Cushing’s syndrome include surgery and pharmacotherapeutic options, which are discussed in PPP Chapter 46. The most common cause of Cushing’s syndrome however, is chronic administration of supraphysiologic doses of exogenous glucocorticoids. The prevalence of medication-induced Cushing’s syndrome is unknown.