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Did She Have Cushing’s?

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By the time A.A. arrived in my office, she had spent almost a year looking for answers.

In November 2012, she was 45 and struggling to lose weight and keep her blood pressure down. What sounds like a common scenario, however, was anything but.

A.A. was experiencing fatigue and malaise, and the area around her eyes bruised easily. Another puzzling symptom: She said she was acutely aware of her neck. It wasn’t pain, but awareness. She was losing more hair than usual in her brush and had stopped menstruating, and her skin broke open easily. Her primary-care physician thought it was early menopause.

She asked family and friends, but no one had such symptoms at menopause. She was increasingly self-conscious as she gained weight. Her primary-care provider referred her to an OB/GYN, and a variety of tests came back normal, including a pap, thyroid, female hormones, and a transvaginal ultrasound.

Worst of all, A.A. struggled emotionally. She felt as though she were in a constant state of agitation, with depression and anxiety. A.A.’s symptoms slowly took over her life. She was becoming a person she hardly recognized.

In July, she ran into a friend who was a nurse. Noticing the puffiness of her face, the nurse asked A.A. whether she was on prednisone. Learning she wasn’t, the nurse suggested A.A. might have Cushing’s syndrome, which results from too much cortisol in the body for long periods. It can be caused by taking a corticosteroid, like prednisone, or by something inside the body signaling the adrenal glands to produce too much of the hormone.

A visit to an endocrinologist confirmed the diagnosis after a 24-hour urine-cortisol test, and an MRI appeared to reveal a small adenoma on the pituitary gland. The endocrinologist referred her to Jefferson to see a surgeon.

Although she was not looking forward to brain surgery, A.A. was relieved to have an answer.

But neurosurgeon James Evans, Jefferson’s director of pituitary surgery, did not think the Cushing’s was caused by the pituitary adenoma. He ordered an additional MRI and blood work, which confirmed his hunch, and he referred her to Jefferson Endocrinology for further detective work.


Solution

When A.A. walked into my office, she was extremely stressed and exhausted. I ordered a chest CT, which revealed a nodule. But it did not fluoresce during a nuclear medicine test, as it likely would have had it been causing the Cushing’s. Next up was a series of scans, but all came back clear.

I still felt the tumor should come out and referred her to cardiothoracic surgeon Scott Cowan.

Three days after surgery to remove one lobe of her lung and the tumor, A.A.’s face already was noticeably slimmer.

Her Cushing’s was caused by a carcinoid tumor the size of a pencil eraser in her lung. The tumor – although not large enough to fluoresce during testing – had been signaling her adrenal glands, which produced enough cortisol, the fight-or-flight hormone, for 24 people.

Cushing’s accounted for all her physical and emotional symptoms. The syndrome can be missed because it mimics obesity in many ways.

With the tumor out, her adrenal glands would effectively go to sleep. She’d need prednisone, which would slowly be tapered over the next year. Fortunately, A.A.’s lymph nodes were clear, and she did not need radiation or chemotherapy.

Over the next year, A.A. got her life and her body back. By January, A.A. was completely off prednisone, feeling and looking like herself.
Read more at http://www.philly.com/philly/health/20150412_Could_brain_surgery_solve_her_baffling_symptoms_.html#xPCBW4wRoFxTCWDh.99

Lee B, Ectopic (pituitary and lung tumor) Bio

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Another Golden Oldie, Lee had both pituitary and lung tumors.  This bio was originally posted 06/07/2008.

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Whee1 where to start!. During 2002 noticed that I had extreme daily hair loss, weight gain even while on diet, depression and general feeling of not being well and decreased sleep and change in sleep pattern. Went to a psychologist who said I was “sane” and diagnosed me with depression related to organic disease.. but what? the fatigue increased – looked like a walking zombie and could barely make it through the day. I worked in a very high powered job. Started experiencing rapid heartbeat – and landed up twice in the ER. Before going to the cardiologist I had a chest xray and saw a shadow on my lung. As an ex-smoker I was concerned and ordered a CT with contrast. I am an RN with a background in Oncology. to cut a long story short, landed up at the oncologist who agreed with me regarding the need for a biopsy. I had to fire my GP who told me to wait another 6 months and do a repeat. I diagnosed myself with a carcinoid tumor, had the upper part of my right lung removed.

I kept on complaining of increased symptoms – moon face, fatigue, headaches, joint pain etc. Got diagnosed with sleep apnea. My oncologist pooh poohed everything but further staining of my lung tumor indicated that it was secreting ACTH – Cushings!

Had a brain MRI – my sella is totally empty and I have a 7mm tumor – not sure what even after 3 MRI’s. Had a full endocrine workup – the endocrinologist siad everything was fine! HA! Turned out I have Hashimoto’s with thyroid cancer – just had that removed. My thyroid was so swollen including the lymph nodes which made me suspicious for metastases- that they could not visulize the Recurrent Nerve – so now I have permanent vocal cord damage and cannot work.

Before this I decided to go to see Dr Friedman. What a blessing. I have adrenal insufficiency, he thinks intermittent Cushings from another carcinoid tumor, who knows where and extreme growth hormone deficiency. I need to have the pituitary tumor removed but am awaiting recovery after my thyroid operation.

I feel terrible – cannot really function, cry all the time, have severe headaches, joint aches, nausea etc. I hope and pray that the pituitary operation will fix up my problems.

Sonja D (Kiwi), Ectopic Bio

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Diagnosed in 2003 with a Carcinoid Lung Tumour which was surgically removed in May 2003.

After a number of years of “not feeling myself” and consulting with the family doctor, it wasn’t until I showed him hair growth on my face and asked him if we had completed all and every test possible related to hormones.

Two tests to do; one was cortisol and the other testesterone.  Results were in the next day, showing cortisol levels four times the normal range.  Bingo!  it was like I had won the lottery.

A flurry of additional tests were conducted, a visit to an Internal Medicine Specialist and finally a referral to the Endocrinologists at the University Hospital.  On meeting the endocrinologist her first words were: “It’s very nice to meet you.  I’m very excited you were able to come in today’.  Is she nuts, I thought.  Since when is a doctor “excited” to meet a patient?  This was the beginning of a most wonderful patient/doctor relationship and it continues today along with the full team of endocrins at this hospital.

It was confirmed I had Ectopic Cushing’s Syndrome in February 2011.  My health deteriorated rapidly with no sign of any tumour which was likely the cause of the extremely elevated ACTH and Cortisol levels.   A Bilateral Adrenalectomy was performed in May 2011 and in November 2011 the elusive lung tumour was sighted in the same location as the one removed in 2003.  It has not grown in the last six months so it is being left “undisturbed” at this stage.

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