Final Diagnosis: ACTH-dependent Cushing’s syndrome • ectopic ACTH syndrome
Symptoms: Edema • general fatigue • recurrent mechanical fall
Medication: —
Clinical Procedure: —
Specialty: Critical Care Medicine • Endocrinology and Metabolic • Family Medicine • General and Internal Medicine • Nephrology • Oncology
Objective:
Unusual clinical course
Background:
Adrenocorticotropic hormone (ACTH)-dependent Cushing’s syndrome (CS) secondary to an ectopic source is an uncommon condition, accounting for 4–5% of all cases of CS. Refractory hypokalemia can be the presenting feature in patients with ectopic ACTH syndrome (EAS), and is seen in up to 80% of cases. EAS can be rapidly progressive and life-threatening without timely diagnosis and intervention.
Case Report:
We present a case of a 74-year-old White woman who first presented with hypokalemia, refractory to treatment with potassium supplementation and spironolactone. She progressively developed generalized weakness, recurrent falls, bleeding peptic ulcer disease, worsening congestive heart failure, and osteoporotic fracture. A laboratory workup showed hypokalemia, hypernatremia, and primary metabolic alkalosis with respiratory acidosis. Hormonal evaluation showed elevated ACTH, DHEA-S, 24-h urinary free cortisol, and unsuppressed cortisol following an 8 mg dexamethasone suppression test, suggestive of ACTH-dependent CS. CT chest, abdomen, and pelvis, and FDG/PET CT scan showed a 1.4 cm right lung nodule and bilateral adrenal enlargement, confirming the diagnosis of EAS, with a 1.4-cm lung nodule being the likely source of ectopic ACTH secretion. Due to the patient’s advanced age, comorbid conditions, and inability to attend to further evaluation and treatment, her family decided to pursue palliative and hospice care.
Conclusions:
This case illustrates that EAS is a challenging condition and requires a multidisciplinary approach in diagnosis and management, which can be very difficult in resource-limited areas. In addition, a delay in diagnosis and management often results in rapid deterioration of clinical status.
It took approximately 6 years for me to be diagnosed with Cushing’s Disease. I have had many unrelated illnesses up to that point, Congestive Heart Failure, FMD, Gallbladder Removed, problems with vision, high blood pressure, weight gain, problems with balance and more.
No doctor could figure out why the weight gain only in my belly. All were prescribing different diets.
My husband and I were on vacation for a month in Florida every morning and afternoon I would walk on the beach 3 miles each time and my belly kept getting bigger???? My husband saw an article on excessive cortisol and how it was a stress hormone and that excessive cortisol expanded your belly!
My daughter had a friend who was an endocrinologist, I made an appointment to see him when we got home. At first sight the doctor said I do not believe you have “it” but to appease you I will test you. To this day I do not believe he would have tested me if he was not friends with my daughter. I did not have any of the typical signs. Non of us is textbook, we are all individuals.
To the doctors surprise testing came back positive for Cushing’s Disease the doctor said that he would have to send you to someone more familiar with Cushing’s and he sent me to Mass General. I met with a Dr. Tritos who once again said I did not have the typical signs and I was retested. Yup it was Cushing’s. I met with a nurosurgeon at Mass General, Dr. Sweringen, who had extensive experience in Cushing’s surgeries.
My insurance company denied my out of network coverage. I saw a few doctor’s locally and did not feel comfortable with any local surgeons because of the lack of surgical experience with Cushing’s Disease. I began my battle with the insurance to have the out of network covered. I was first rejected by the insurance company, I then appealed with Maximus (second step in process) and was rejected. During this time my health was deteriorating, I had double vision and could no longer drive, I needed to hold onto someone to walk because I had become so unsteady. My family was worried because they had read that the longer you waited for surgery chances were less likely for a full recovery. My daughter gave me the money for the surgery which I had at Mass General on November 16, 2016 by Dr. Sweringen, who is fantastic! I had successful Pit surgery.
After surgery I continued my pursuit in getting the money back. I went to the next level, the applet judge……This time I won, with the help of my local endocrinologist, Dr. Busch and documented proof of Dr. Sweringens exceptional expertise in Pituitary Surgery.
Now almost 10 months later, I am very surprised that I still have muscle weakness and joint pain. When I mention this to doctors they do not believe it is Cushing’s related, even though when you go to the Cushing’s Facebook support group people mention this. I am wondering how many others have this problem 10 months post op. I still have trouble getting out of a chair.
What is so sad you are not told about the post op obstacles you will face.
I think that all of us facing this disease have to give ourselves credit for the strength we have and have to continue having to battle this disease, and to appreciate our support of family and friends.
This is about my husband…2010 diagnosed with rheumatoid arthritis (one day he was fine, the next day he was in agony type onset). Was placed on methotraxate, prednisone, humera, actemra, etc. for the next 4 or 5 years. None of the bilogics worked for more than a month. Pred and pain meds became a mainstay for about 5 years. I started to question the accuracy of the diagnosis and was patted on the head and basically told to forget it and go my merry way and accept it. We were always told the bloodwork “was fine. no issues with the exception that when Neal hurt, his inflammatory blood factors were low..which was odd but it is his body”. It was left at that. We basically gave up the Rheumatologist in 2015 as it was getting us nowhere and nothing was changing. Something was still wrong.
Late 2015, his weight gain went crazy. He developed moon face, the traditional hump on the back of his neck, huge adbdomen with tons of stretch marks everywhere, no energy, listlessness, severe pitted edema, paper thin skin, spots all over his legs, rash on his chest, pressure on his chest and lungs when laying down, sleeping all of the time (as in 2 seconds after he hit is recliner), sleeping solely in the recliner, lower extremety severe weakness, nausea, etc. This led to congestive heart failure in Jan 2016 due to the extreme fluid retention. Placed on lasix, indomethacin, blood pressure meds. Cleared by heart doc two weeks later to return to work.
Still no results…..still spiraling downhill. March 2016 Get steroid injection in the knees as he cannot walk due to the weakness, swelling and pain. Vision issues are now added to the list of continuing issues.
June 7, 2016. Go to another doctor out of state and get more bloodwork done as we cannot take it anymore. They take more blood. Doc does comment on his paper thin skin and mentions that is usually from steriod use. Neal passes out and has to be taken out of the office in a wheel chair as he cannot walk due to the extreme weakness and pain. Increase lasix to 2 a day and get prednisone.
I have finally had enough. I cannot stand seeing my once vibrant active husband just laying there…just existing….just barely…. I make a comprehensive list of all of his symptoms, make a graph of his blood work results from 2010 to present…what I found was astonishing…his results were NOT ok. I took him to the local doctor and pleaded and begged for him to figure out what is wrong with my husband. I initially go thte ole “I don’t want to step on anyone’s toes” etc. as we had just gone to the new rheum. doc a week ago. He ordered a new echocardiogram and it was clear. Added new drug. Neal had an allergic reaction and was put on high dose (50 mg daily) of prednisone combined with zantac and zyrtec for 3 days.
A week later, his bloodwork came back…gout, hypothyroid (based on symptoms), severe internal infection. Add more meds.
Go to eye doc and get the diagnosis of cateracts in both eyes. Doc felt it was due to prednisone due to the rapid onset. Surgery scheduled for next week.
In the meantime, Neal has gone even more downhill….now he feels like he periodically fractures a rib, a finger, etc. Even more stretch marks are present. He is listless and cannot function. He cannot walk. Add decreased urine output even on the lasix). He just lays there stuck in a shell. He has missed so much work in the past 2 weeks. He lives as one would in a nursing home…I take care of his daily needs. He cannot.
I go back to doing my research online. Cushings Syndrome pops up…OMG….Between all of the biologics, the up and down on the prednisone, zyrtec, steroid injections , etc. has sent him into the major downward spiral that he is experiencing…..Steroid induced Cushings along with hypothyroidism (might even be hashimoto’s..too soon to tell). We came to this conclusion at 2 am this morning. To further prove this, he took an additional 10 mg of prednisone immediately. I know…he refused to go to the er…he wanted to prove it one way or the other. (I did tell him that I was gonna invoke my medical poiwer of attorney and have him taken out by ambulance on tuesday if not sooner if this didn’t have some impact). Well…he can WALK this morning. He actually went to the bathroom to use the toilet….THAT is a huge deal to us. He is in pain but he can MOVE!!!! He went to work this afternoon as well. He has to have his cateract surgery so he can see to work (we will lose our home…company house…and everything else if this is not done asap). That is his priority. Once the surgery is done, we will be headed back to Nebraska to approach the doctor there about our findings relating to Cushings Syndrome.
My name is Meriam San Antonio, 52 years old from Fairfield, California. I have been married for 19 years and have three teenage children. I was sick for almost 7 months ( starting March 2013) and the doctors couldn’t figure out what is wrong with me. My symptoms were being bloated, had edema on my feet and legs, swollen all over, had a “moon face”, bruising on my hands, myopathy/neuropathy, aching nerves, bloated stomach (as if I was pregnant), double vision, and lost my ability to walk.
I have been in and out of the ER due to having a congested heart failure, urinary tract infection, colonitis. I suffered from acute depression and tried killing myself. My blood pressure and blood sugar was soaring so high and uncontrolled.
After a series of tests, I was finally diagnosed of having Cushing’s syndrome. A surgery was done on August 2013 to removed my pituitary gland at the left side of my brain.. I had to take an early retirement from work and currently on Social Security Disability.
Two years had past and I have recovered. I lost weight, my blood sugar and blood pressure were now on the normal range. It seems after the surgery, everything was back to normal. I can now walk on my own ( without the help of a cane, walker and wheel chair) but had to undergo a knee replacement as I fell many times on my knees due to nerve weakness. I had a rough time and had gone through a lot.
I stopped taking my PTU medication as told by my doctor as I am already “Cushing’s free”.
But my endocrinologist just informed me that the result of my thyroid test was high. She ordered me to take a “nuclear iodine test” next week. I am so worried that my Cushing’s will come back. I do not want to undergo such experience as I was so traumatized by it.
Hi, my name is Meriam from California, a 51 years old female. I was diagnosed with Cushing’s last August 2013.
I had all the typical symptoms (weight gain, edema, purple marks, bruising, aches all over the body, hair loss, depression, anxiety, uncontrolled diabetes, high blood pressure, high cholesterol, poor concentration, sleep apnea, etc.) I thought all of these problems was partly caused by my weight gain (230 lbs.). I underwent a gastric by-pass but still didn’t lose weight that much.
Eventually. my body seems to shut down and had been and out of the ER. I suffered congestive heart failure, blood clot, blurred/double vision, colon inflamation, body pains and aches, myopathy but the hardest part was, I lost my ability to walk.
It was a rough year for me; been hospitalized for almost a year. Finally, after 6 months of suffering, my Endocrinologist was able to diagnosed me of having Cushings.
My pituitary gland was removed and was given the necessary treatments. As my cortisol level went down, most of my symptoms disappeared except for bouts of body aches and depression.
I am currently doing physical therapy to be able to walk on my own again. I lost weight and on the way to recovery.
My greatest fear is for the Cushing’s to come back and I do not want to undergo the same ordeal again.
Hello, my name is Bev I have 8 kids yes that is not a typo :)…
I have been fighting whatever is wrong with me for the last 16 yrs. I have been diagnosed in the past as having a thyroid problem. That was always changing( hypo to hyper thyroidism) and now I am told my thyroid is fine. I was diagnosed with fibromyalgia and PCOS.
Now in the last year I have gained about 100 lbs. …No matter what I eat or how much I exercise…. I recently went to the ER because of way more than usual water retention along with chest pain and shortness of breath. They tested me for congestive heart failure, and that is not the problem.
After many blood test and etc. they have “unofficially” said I have Cushings. I go to see the Endoconologist in a week. I dont want to have this as I know noone else does! But it would be a relief to know what is actually wrong with me….. I am tired of this emotional and painful roller coaster my body has me on.
Confused and scared about what is going to happen.
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