Comprehensive Case Study: Management of Hypercortisolism in a Patient with Cushing's Disease
A 34-year-old married woman with Cushing's Disease and hypercortisolism presented with various symptoms including galactorrhea, weight gain, hirsutism, acne, and dysglycemia. Following transsphenoidal surgery (TSS), she experienced clinical and biochemical recovery, with improvements in weight, hirsutism, BP, and menstruation. Despite initial improvements, issues like irregular menstruation persisted post-surgery. Lab data revealed cortisol and ACTH levels, as well as FSH, LH, TSH, and prolactin values. Close monitoring and multidisciplinary management were crucial in her treatment journey.
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Patient ID: A 34 y-o , Bachelor of Art, married, housewife, born & living in Tehran.
CC:referred for management of hypercortisolism after radiotherapy PI: The patient is a known case of Cushing s Disease underwent TSS in 92/6/14,she has been advised to follow by UFC every 6 month. She was diagnosed to have disease recurrence according to high UFC in 95/8/1,no other findings except mild irregularity in menstruation.
The primary manifestation of disease was spontaneous galactorrhea & she received bromocriptine for more than 1 year by prescription of a gynecologist. During the following year, she had complaint of central obesity & weight gain (11 kg, 52 63 kg),hirsutism, acne and striae,in addition to dysglycemia & mild increase in BP. She was also suffering from amenorrhea which did not respond to medical treatment (OCP),moreover despite consumption of bromocriptine, galactorrhea was started again. She was referred to an endocrinologist for more investigation.
Lab Data: 92/4/13 960 mcg/24h (50-190) 92/4/16 872 mcg/24h 92/4/23 235 mcg/24h (HDDT) (75% suppression) UFC Cortisole 8a.m. ACTH 34 mcg/dl 46 pg/ml
92/3/29 FSH 3.7 mIu/ml LH 1 mIu/ml TSH 0.1 mIu/m T4 5 mcg/dl Prolactin 87 ng/ml FBS 107 K 4.5
She was underwent TSS in Loghman hospital. She had clinical & biochemical recovery after surgery(weight loss, regression of hirsutism & acne, normalization of BP & menstruation, discontinuation of metformin and normalization of UFC). She states; she has have irregularity in menstruation since menarche but this problem was obviated after TSS. She had a Hx of corticosteroid & levothyroxine consumption for two weeks after surgery.
One month after surgery Cortisol 8 a.m. : 12 mcg/dl UCF: 22 mcg/24h , Ucr:0.8 gr/24h
She was diagnosed to have recurrence due to high UFC& oligomenoreha 7 month ago. Headache (-) blurred vision(-) asthenia(-) weight gain(-) muscle weakness(-) easy bruising(-) nausea(-)
95/4/19 101 (50-190) Still nl 95/8/1 404 95/8/16 301 95/8/18 55 (LDDT) 95/8/20 189 (HDDT) 95/11/6 96/1/27 215 UFC mcg/d 416 ACTH 36.1 Cortisol 8a.m. mcg/dl Prolactin ng/ml 28 9.46 8.68 19.59 24 FBS TSH T4 93 105 1.1 9.27 96 0.9 7.2
According to neurosurgery consult she was not candidate for resurgery and she was referred to conventional radiotherapy (that was ended in 96/1/15) Since 96/2/2,she has been under treatment of ketoconazole 200mg BID
Family history: she is mother of two children(13 & 7 y-o) CVA in mother Drug history: ketoconazole 200mg/BD metformin 500 mg/d
Ph/E: A young woman who was not well cooperative in history taking, she seems to had mood labiality and cried several times during interview; she was so concerned about her illness. Weight:53kg Height:160 cm BMI:21 WC:81cm BP: 100/70 PR:88 Central obesity(+) Skin atrophy(-) Telangiectasia(-) Ecchymosis(-) H&N: moon face(-) dorsocervical fat pad (-) supraclavicular fat pad(-)
ChestNl Abdomen: striae(+) Ext: muscle force Nl peripheral edema(-) muscle atrophy (-)
BMD Now (96/2/23) by DMS (STARTOS MODEL) densitometer Then (92/4/30) by Osteosys XR-600 densitometer
UFC one month after ketoconazole (24/2/96): UFC: 230 mcg/24h (60-137), Ucr:1.02 gr/24h
Problem List: A young Recurrence after TSS without full-blown clinical features of disease. Underwent conventional radiotherary Under treatment of ketoconazole 400mg/d (high UFC by this treatment) known case of CD
