Case presentation

Done by: Dr. Rahma ShahBahai

Medical intern

History
36 y.o single Saudi female k/c of HTN, T2DM and dyslipidemia
Direct admission from OPD.
Presented with lower back pain, headache and inability to
walk for 3 months.
referred from KFH (Hafof) for persistent hypokalemia for
further investigation.

HPI:
3 months Hx of progressive bilateral lower limbs weakness.
Start as a simple weakness>>cant carry her weight during
standing>>become wheelchair bound.
Headache and lower back pain.
No Hx of sphincter incontinence.

Drug Hx:
Aldactone 50 mg PO BID
Nifedipine 40 mg PO OD
Hydralazine 50 mg PO Q6H
Atorvastatin 20 mg PO OD
Labetalol 100 mg PO BID
Diamicron 90 mg PO OD

PH:
uncontrolled HTN >10 years
Dyslipidemia+T2DM ~3month
2ry Amenorrhea ~15 yrs.
Her menarche @ 13>> stopped
didn't seek medical advice.
No surgical Hx.

FH:
father in good health.
Mother >>HTN
Sis1: HTN+DM
Sis 2: passed away (leukemia)
sis 3: weight gain+2ry amenorrhea

Systemic review:
No mood changes
No dizziness
No blurred vision
excessive hair growth
acne
No respiratory or cardiac symptoms
No nausea, vomiting, diarrhea or constipation
No urinary symptoms

D.Dx ???

Examination

General:

Obese, round face, comfortable in the bed, not in distress.

Vitals: T 37.7 ,p 90, RR 18, BP 160/100

Skin:

hirsutism, facial plethora, acne, dorsocervical fat deposition, supraclavicular

fat deposition.

Chest: clear, good air entry bilateral.

CVS: S1,S2+0

Abdomen: distended, White striae ~0.5-0.7 cm, positive bowel sound.

CNS: conscious, alert

Extremities: bruises
U.L: power 4/5, reflexes normal
L.L: muscles wasting, bruises, no edema, power 3/5, reflexes normal

Labs:
Cbc
Liver panel
Renal/lyte
Lipid profile
All within her base line, except for:
K 2.5

Hospital course
Pt. loss of her consciousness < 1min.
Notice abnormal movement, not typical for convulsion
K 2.4
ICU transferred.
Observation, K-replacement, ECG

Investigations???

Labs:

Cortisol level am 313.6

Cortisol level pm 2017.8

ACTH 31

DST 331

FT4 13.5

FT3 2.44

T3H 0.09(SET)

E2 142

LH <0.07

FSH 0.09

Brain CT:
cystic density 20*20 nm seen
compressing the pituitary gland

Brain MRI:
cystic mass lesion 2.5*1.7 cm with evidence of
hemorrhagic is seen, optic chiasma is
displaced cronaly
Finding consistent rathke cleft cyst
complicated by hemorrhagic or cystic
degeneration of pituitary macro-adenoma.

Diagnosis is..?
ACTH-dependent Cushings syndrome

Harvey Williams Cushing

Cushings Syndrome= Hypercortisolism

Cushing's disease= Cushing's syndrome 2ry to pituitary ACTH

hypersecretion

Etiologies:
Iatrogenic= exogenous glucocorticoid>>most
common
Cushings disease= endogenous 70%
Pituitary adenoma/hyperplasia

Adrenal tumor 25%

Ectopic ACTH 10%:
Carcinoid, SCLC, medullary thyroid cancer, pheo.

Approach

TTT..
Mainly>>surgical resection
Medication
Replacement therapy lifelong.

Thank you.