| Author | Affiliation |
|---|---|
| Jason D. Vadhan, DO | UT Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas |
| Nathaniel Hansen, MD | UT Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas |
| Fernando L. Benitez, MD | UT Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas |
| Larissa I. Velez, MD | UT Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas |
ABSTRACT
Case Presentation
A 22-year-old female presented to the emergency department with a two-month history of worsening fatigue, unintentional weight gain, and progressive facial swelling. Physical examination findings included hirsutism, moon facies, and abdominal striae. Subsequent brain magnetic resonance imaging revealed the presence of a 2.4-centimeter pituitary macroadenoma, confirming the diagnosis of Cushing’s disease. The patient was then admitted for neurosurgical tumor resection.
Discussion
Cushing’s disease is exceedingly rare and often presents with symptoms resembling more prevalent disorders, contributing to delays in diagnosis. Therefore, maintaining a high index of suspicion for this disease is crucial for emergency physicians.
CASE PRESENTATION
A 22-year-old female with a past medical history of hypertension and diabetes presented to the emergency department with two months of abdominal striae, persistent fatigue, unintentional weight gain exceeding 30 pounds, and progressive facial swelling. Physical exam revealed the presence of abdominal striae (Image 1), facial and trapezius adiposity (Image 2), and hirsutism (Image 3). Since the patient was not receiving steroid therapy at the time, her symptoms raised suspicion for Cushing’s disease. Subsequently, a brain magnetic resonance imaging (MRI) with intravenous contrast was performed, revealing a 2.4-centimeter pituitary macroadenoma causing severe upward displacement of the optic chiasm (Supplementary Image). Neurosurgery was sought, and the patient was admitted for operative management.
DISCUSSION
Cushing’s disease is a rare disorder characterized by excessive cortisol production from the adrenal glands, which can either be from the adrenals directly or from corticotropin-releasing tumors in the lungs or pituitary gland.1 The term “Cushing’s disease” refers explicitly to the presentation of Cushing’s syndrome caused by a pituitary tumor. Cushing’s disease is more commonly observed among women, typically appearing between 20–40 years of age.1 Clinical manifestations are attributed to increased cortisol production, which causes weight gain, fatigue, poor concentration, hypertension, hyperglycemia, excess hair growth, abdominal striae, adipose deposition, and menstrual irregularity.2 Unfortunately, these symptoms are nonspecific and overlap with common medical conditions such as diabetes, hypertension, and polycystic ovarian syndrome. Consequently, the diagnosis of Cushing’s disease is often delayed, with an average time to diagnosis exceeding three years from symptom onset.3
The evaluation for Cushing’s disease is typically initiated in an outpatient setting and involves various tests, including midnight salivary cortisol measurement, low-dose dexamethasone suppression test, or 24-hour urine-free cortisol level assessment.2 However, in the emergency department, obtaining a brain MRI may be warranted to detect a visible pituitary tumor, which can be seen approximately 50% of the time, as in this case.2 When pituitary tumors are discovered, neurosurgical consultation and operative resection are often necessary.
Footnotes
Section Editor: Melanie Heniff, MD
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
Address for Correspondence: Jason D. Vadhan, UT Southwestern Medical Center, Department of Emergency Medicine, 5200 Harry Hines Blvd, Dallas, TX 53235. Email: jason.vadhan@phhs.org. 8:174 – 175
Submission history: Revision received October 29, 2023; Submitted July 12, 2023; Accepted July 13, 2023
Patient consent has been obtained and filed for the publication of this case report.
REFERENCES
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