This case presented in the outpatient setting, which manifests with classic symptoms and utilizes the Cushing Disease diagnostic algorithm. Multiple lab tests and imaging tools are essential to the primary diagnosis, which will be uncovered in this case study.

A 33-year-old female with a past medical history significant for anxiety, vitamin D deficiency, and migraines presents to the outpatient clinic with the chief complaint of being unable to achieve weight loss. The patient works as a nurse and frequently covers night shifts. She expresses increased stress and anxiety, which are managed with alprazolam. Persistent efforts were made to reduce weight, including dietary modifications and a consistent exercise regimen, yet she was unsuccessful. She was also having increased fatigue and sleep difficulty. Her current home medications included escitalopram, alprazolam, and sumatriptan. The presentation appears consistent with a stressed healthcare worker exhibiting common symptoms of weight gain and anxiety in an outpatient setting. Yet the importance of further workup is highlighted in this case. Due to suspicion of adrenal insufficiency, subsequent testing with a low-dose dexamethasone suppression test was indicated revealing AM cortisol of 10.6 ug/dL (normal result). Due to unsuppressed cortisol level, further investigation of two separate salivary cortisol levels were collected. Both levels (0.526 and 0.34) were elevated, confirming hypercortisolism. Initial differentials included Cushings disease, paraneoplastic syndromes, and adrenal hyperplasia.

In differentiation between primary vs. secondary causes, two ACTH levels were taken and abnormally within the normal range (31.7 and 38.3), indicating secondary hypercortisolism. Ultimately an MRI of the pituitary was warranted revealing two separate pituitary microadenomas.

Due to the unusual presentation of multiple microadenomas, the patient was referred to neurosurgery with the ultimate recommendation for inferior petrosal sinus sampling. IPSS confirmed Cushing Disease with hypersecretion from the left side of the pituitary.

Due to the symptomatic nature of the pituitary growths affecting the patient’s daily life, the decision was made for surgical intervention via endoscopic transsphenoidal pituitary resection. The complexity of two pituitary microadenomas resulting in persistent symptoms in a young female is evidenced in this case, also highlighting the importance of further investigation when clinically warranted.

References and Resources

1. Castinetti F, Morange I, Conte-Devolx B, Brue T. Cushing’s disease. Orphanet J Rare Dis. 2012; 7(1): p.41. doi: 10.1186/1750-1172-7-41.| Open in Read by QxMD
2. Feelders R, Sharma S, Nieman L. Cushing’s syndrome: epidemiology and developments in disease management. Clin Epidemiol. 2015: p.281. doi: 10.2147/clep.s44336.| Open in Read by QxMD
3. Nieman LK, Ilias I. Evaluation and treatment of Cushing’s syndrome. Am J Med. 2005; 118(12): p.1340-1346. doi: 10.1016/j.amjmed.2005.01.059.| Open in Read by QxMD