Case presentationDone 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>>can’t 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 Cushing’s syndrome

Harvey Williams Cushing

Cushing’s Syndrome= Hypercortisolism

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

hypersecretion

Etiologies:

Iatrogenic= exogenous glucocorticoid>>most

common

Cushing’s 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….