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Pseudo-Cushing’s syndrome is when symptoms are similar to those of Cushing’s syndrome, but further tests show that the syndrome is not present. Common causes include consuming too much alcohol, obesity, persistently high blood glucose levels, pregnancy, and depression.
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Abstract Cushing’s disease is an abnormal secretion of ACTH from the pituitary that causes an increase in cortisol production from the adrenal glands. Resultant manifestations from this excess in cortisol include multiple metabolic as well as psychiatric disturbances which can lead to significant morbidity and mortality. In this report, 23-year-old woman presented to mental health facility with history of severe depression and suicidal ideations. During evaluation, she found to have Cushing’s disease, which is unusual presentation. She had significant improvement in her symptoms with reduction of antidepressant medications after achieving eucortisolism. Cushing syndrome can present with wide range of neuropsychiatric manifestations including major depression. Although presentation with suicidal depression is unusual. Early diagnosis and prompt management of hypercortisolsim may aid in preventing or lessening of psychiatric symptoms The psychiatric and neurocognitive disorders improve after disease remission (the normalization of cortisol secretion), but some studies showed that these disorders can partially improve, persist, or exacerbate, even long-term after the resolution of hypercortisolism. The variable response of neuropsychiatric disorders after Cushing syndrome remission necessitate long term follow up. Keywords cushing syndrome, cushing disease, hypercortisolism Introduction Endogenous Cushing syndrome is a complex disorder caused by chronic exposure to excess circulating glucocorticoids. It has a wide range of clinical signs and symptoms as a result of the multisystem effects caused by excess cortisol.1 The hypercortisolism results in several complications that include glucose intolerance, diabetes, hypertension, dyslipidemia, thromboembolism, osteoporosis, impaired immunity with increased susceptibility to infection as well as neuropsychiatric disorders.2,3 Cushing syndrome presents with a wide variety of neuro-psychiatric manifestations like anxiety, major depression, mania, impairments of memory, sleep disturbance, and rarely, suicide attempt as seen in this case.2,4 The mechanism of neuropsychiatric symptoms in Cushing’s syndrome is not fully understood, but multiple proposed theories have been reported, one of which is the direct brain damage secondary to excess of glucocorticoids.5 Case Report A 23-year-old female presented to Al-Amal complex of mental health in Riyadh, Saudi Arabia with history of suicidal tendencies and 1 episode of suicidal attempt which was aborted because of religious reasons. She reported history of low mood, having disturbed sleep, loss of interest, and persistent feeling of sadness for 4 months. She also reported history of weight gain, facial swelling, hirsutism, and irregular menstrual cycle with amenorrhea for 3 months. She was prescribed fluoxetine 40 mg and quetiapine 100 mg. She was referred to endocrinology clinic at King Fahad Medical City, Riyadh for evaluation and management of possible Cushing syndrome as the cause of her abnormal mental health. She was seen in the endocrinology clinic where she reported symptoms as mentioned above in addition to headache, acne, and proximal muscle weakness. On examination her vital signs were normal. She had depressed affect, rounded face with acne and hirsutism, striae in the upper limb, and abdomen with proximal muscle weakness (4/5). Initial investigations showed that 24 hour urinary free cortisol was more than 633 µg which is more than 3 times upper limit of normal (this result was confirmed on second sample with level more than 633 µg/24 hour), cortisol level of 469 nmol/L after low dose 1 mg-dexamethasone suppression test and ACTH level of 9.8 pmol/L. Levels of other anterior pituitary hormones tested were within normal range. She also had prediabetes with HbA1c of 6.1 and dyslipidemia. Serum electrolytes, renal function and thyroid function tests were normal. MRI pituitary showed left anterior microadenoma with a size of 6 mm × 5 mm. MRI pituitary (Figure 1). Figure 1. (A-1) Coronal T2, (B-1) post contrast coronal T1 demonstrate small iso intense T1, heterogeneous mixed high, and low T2 signal intensity lesion in the left side of anterior pituitary gland which showed micro adenoma with a size of 6 mm × 5 mm. (A-2) Post-operative coronal T2 and (B-2) post-operative coronal T1. Demonstrates interval resection of the pituitary micro adenoma with no recurrence or residual lesion and minimal post-operative changes. There is no abnormal signal intensity or abnormal enhancing lesion seen. No further hormonal work up or inferior petrosal sinus sampling were done as the tumor size is 6 mm and ACTH level consistent with Cushing’s disease (pituitary source). She was referred to neurosurgery and underwent trans-sphenoidal resection of the tumor. Histopathology was consistent with pituitary adenoma and positive for ACTH. Her repeated cortisol level after tumor resection was less than 27 and ACTH 2.2 with indicated excellent response to surgery. She was started on hydrocortisone until recovery of her hypothalamic pituitary adrenal axis documented by normal morning cortisol 3 months after surgery (Table 1). Table 1. Labs. Table 1. Labs. View larger version During follow up with psychiatry her depressive symptoms improved but not resolved and she was able to stop fluoxetine 5 months post-surgery. Currently she is maintained on quetiapine 100 mg with significant improvement in her psychiatric symptoms. Currently she is in remission from Cushing’s disease based on the normal level of repeated 24 hour urinary free cortisol and with an over-all improvement in her metabolic profile. Discussion Cushing syndrome is a state of chronic hypercortisolism due to either endogenous or exogenous sources. Glucocorticoid overproduction by adrenal gland can be adrenocorticotropic (ACTH) hormone dependent which represent most of the cases and ACTH independent.6 To the best of our knowledge this is the first case documented in Saudi Arabia. There are multiple theories behind the neuropsychiatric manifestations in Cushing syndrome. These include increased stress response leading to behavioral changes, prolonged cortisol exposure leading to decreased brain volume especially in the hippocampus, reduced dendritic mass, decreased glial development, trans-cellular shift of water and synaptic loss, and excess glucocorticoid levels inhibiting neurogenesis and promoting neuronal tendency to toxic insult.3,7 In this report, the patient presented with severe depression with suicidal attempt. She had significant improvement in her symptoms with reduction of antidepressant medications but her depression persisted despite remission of Cushing disease. A similar case has been reported by Mokta et al,1 about a young male who presented with suicidal depression as initial manifestation of Cushing disease. As opposed to the present case he had complete remission of depression within 1 month of resolution of hypercortisolism. In general, psychiatric and neurocognitive disorders secondary to Cushing syndrome improves after normalization of cortisol secretion, but some studies showed that these disorders can partially improve, persist, or exacerbate, even long-term after the resolution of hypercortisolism. This may be due to persistence hypercortisolism creating toxic brain effects that occur during active disease.2,8 Similar patients need to be followed up for mental health long after Cushing syndrome has been resolved. Conclusion Depression is a primary psychiatric illness, that is, usually not examined for secondary causes. Symptoms of depression and Cushing syndrome overlap, so diagnosis and treatment of Cushing disease can be delayed. Early diagnosis and prompt management of hypercortisolsim may aid in preventing or lessening psychiatric symptoms. The variable neuropsychiatric disorders associated with Cushing syndrome post-remission necessitates long term follow up. Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article. Informed Consent Written informed consent was obtained from the patient for the publication of this case and accompanying images. ORCID iD Sultan Dheafallah Al-Harbi https://orcid.org/0000-0001-9877-9371 References 1. Mokta, J, Sharma, R, Mokta, K, Ranjan, A, Panda, P, Joshi, I. Cushing’s disease presenting as suicidal depression. J Assoc Physicians India. 2016;64:82-83. Google Scholar | Medline 2. Pivonello, R, Simeoli, C, De Martino, MC, et al. Neuropsychiatric disorders in cushing’s syndrome. Front Neurosci. 2015;9:1-6. Google Scholar | Crossref | Medline 3. Pereira, AM, Tiemensma, J, Romijn, JA. Neuropsychiatric disorders in Cushing’s syndrome. Neuroendocrinology. 2010;92:65-70. Google Scholar | Crossref | Medline | ISI 4. Tang, A, O’Sullivan, AJ, Diamond, T, Gerard, A, Campbell, P. Psychiatric symptoms as a clinical presentation of Cushing’s syndrome. Ann Gen Psychiatry. 2013;12:1. Google Scholar | Crossref | Medline 5. Sonino, N, Fava, GA, Raffi, AR, Boscaro, M, Fallo, F. Clinical correlates of major depression in Cushing’s disease. Psychopathology. 1998;31:302-306. Google Scholar | Crossref | Medline 6. Wu, Y, Chen, J, Ma, Y, Chen, Z. Case report of Cushing’s syndrome with an acute psychotic presentation. Shanghai Arch Psychiatry. 2016;28:169-172. Google Scholar | Medline 7. Rasmussen, SA, Rosebush, PI, Smyth, HS, Mazurek, MF. Cushing disease presenting as primary psychiatric illness: a case report and literature review. J Psychiatr Pract. 2015;21:449-457. Google Scholar | Crossref | Medline 8. Sonino, N, Fava, GA. Psychiatric disorders associated with Cushing’s syndrome. Epidemiology, pathophysiology and treatment. CNS Drugs. 2001;15:361-373. Google Scholar | Crossref | Medline From https://journals.sagepub.com/doi/10.1177/11795476211027668 -
For years before and after their diagnosis, people with Cushing’s disease use more psychotropic medications — those that affect mood, thoughts, or perception — for mental health problems than their healthy peers, a study in Sweden found. Notably, patients experiencing long-term disease remission still showed higher use of antidepressants and sleeping pills than healthy individuals. These findings highlight Cushing’s persistent negative effects on mental health, according to researchers. Additionally, the results of this study, based on prescribed medication dispenses in Sweden, support the importance of earlier diagnoses of Cushing’s disease — and the need for close and long-term monitoring of neuropsychiatric symptoms in this patient population, the researchers said. The study, “Psychotropic drugs in patients with Cushing’s disease before diagnosis and at long-term follow-up — a nationwide study,” was published in the Journal of Clinical Endocrinology & Metabolism. Mental health issues such as anxiety, depression, sleep disturbances, and cognitive impairments are part of the wide range of symptoms caused by the abnormally high levels of the cortisol hormone that characterize Cushing’s syndrome. Of note, Cushing’s disease is a form of Cushing’s syndrome caused by a tumor in the pituitary gland. A “few” studies have reported the elimination or partial lessening of neuropsychiatric symptoms after successful Cushing’s treatment, according to the researchers. But others noted that “impaired cognitive function and quality of life seemed to persist for a long time after biochemical [cortisol level-based] remission had been achieved,” the team wrote. Now, these researchers, from several universities in Sweden, have assessed the use of psychotropic medications — reflecting mental health burden — in 372 people with Cushing’s disease. The use of such medications was assessed five years before diagnosis, at the time of diagnosis, and at five and 10 years post-diagnosis. The patients, diagnosed between 1990 and 2018, were identified through the Swedish Pituitary Register, which covers 95% of all people with Cushing’s disease in the country. Most of the patients (76%) were women. Altogether, the patients’ mean age at diagnosis was 44 years. For each individual with Cushing’s, four sex-, age-, and residential area-matched healthy individuals were used as controls for comparative analyses. Data on each individual’s dispenses of medications commonly used for neuropsychiatric issues were obtained from the Swedish Prescribed Drug Register. This register, which fully covers all prescribed medications given throughout the country, also was used to determine each patient’s dispenses of other medications for Cushing’s disease symptoms, such as high blood pressure, also called hypertension, and diabetes. The results showed that the use of antidepressants, anxiolytics — medications to lessen anxiety — and sleeping pills was at least twofold higher in Cushing’s patients than in healthy individuals during the five-year period before diagnosis, and at the time of diagnosis. Five years after diagnosis, the proportion of patients using antidepressants (26%) and sleeping pills (22%) remained unchanged, and even individuals in remission showed significantly higher use of such medications than did controls (20–26% vs. 8.6–12%). According to the results, one-third of the patients on antidepressants since their diagnosis were able to discontinue treatment before the five-year assessment — most having achieved disease remission. However, 47% of those receiving antidepressants at five years had initiated such treatment at a median of 2.4 years after diagnosis. During the five-year follow-up, older age and being a woman appeared to increase the risk of antidepressant use among Cushing’s disease patients. At 10 years of follow-up, the use of antidepressants and sleeping pills was not significantly different between groups, despite the fact that antidepressants use remained about the same among patients. Notably, researchers conducted an analysis of 76 patients with sustained remission for a median of 9.3 years, and 292 matching controls. That analysis showed that the use of antidepressants and sleeping pills was significantly higher among patients. The use of other medications, such as those for hypertension and diabetes, also was significantly more common among Cushing’s disease patients before, at diagnosis, and at five years post-diagnosis — although the post-diagnosis numbers dropped by half during that period. After 10 years, only the use of anti-diabetic medications remained significantly higher in patients as compared with controls. These findings suggest that other conditions associated with Cushing’s disease, such as hypertension and diabetes, are effectively lessened with treatment. However, they also highlight that “many patients with CD [Cushing’s disease] will have persistent mental health problems,” the researchers wrote. In addition, visits to a psychiatrist and hospital admissions for treatment of psychiatric disorders tended to be more common among Cushing’s disease patients, even before diagnosis, the team noted. “This nationwide register-based study shows that use of psychotropic drugs in CD patients is increased from several years before diagnosis,” the researchers wrote, adding that this use “remained elevated regardless of remission status, suggesting persisting negative effects on mental health,” the researchers wrote. These findings highlight the importance of early diagnosis of Cushing’s disease and of considering neuropsychiatric symptoms “as an important part of the disease,” they concluded. There is a “need for long-term monitoring of mental health” in Cushing’s, they wrote. From https://cushingsdiseasenews.com/2021/02/24/cushings-found-to-cause-persistent-negative-mental-health-effects-swedish-study/
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Written by Kathleen Doheny With Oskar Ragnarsson, MD, PHD, and Tamara Wexler, MD, PhD Adults with Cushing's syndrome, also called hypercortisolism, have a three-fold higher risk of dying from heart disease compared to the general population,1 according to findings reported by a Swiss research team. Although the researchers found that the risk drops when patients are under care, receiving treatment, and are in remission, the risks don't disappear completely. For some perspective, heart disease is common in the United States, affecting, one in four adults, regardless of health status.2 "Patients with Cushing's disease have excess mortality [risk]," says Oskar Ragnarsson, MD, PhD, associate professor and a senior consultant in internal medicine and endocrinology at Sahlgrenska University Hospital in Gothenburg, Sweden. He is the author of the study, which appears in the Journal of Clinical Endocrinology & Metabolism. Having Cushing's Requires Vigilance Beyond Disease Symptoms Still, the news is not all bleak, he says. Simple awareness of the increased risks can help individuals reduce their risk, just as following your doctor’s treatment plan so remain in remission, Dr. Ragnarsson tells EndocrineWeb. In addition, patients who received growth hormone replacement appear to have better overall outcomes.1 Cushing’s syndrome occurs when your body is exposed to high levels of the hormone cortisol over a long period of time. This can be caused either by taking corticosteroid medicine orally, or if your body just makes too much cortisol. Common symptoms of this condition include: having a fatty hump between the shoulders, a rounded face, and stretch marks with pink or purple coloring on the skin. Complications, if Cushing’s disease goes untreated, may include bone loss (leading to increased risk of fractures and osteoporosis), high blood pressure, type 2 diabetes, and other problems. Usual treatment includes medication and surgery that are aimed to normalize cortisol levels.3 Increased Risks Are Cause for Concern in Cushing’s Disease The researchers analyzed data from 502 men and women, all of whom were diagnosed with Cushing's disease between 1987 and 2013 as indicated in a Swedish health database.1 The average age of these patients at diagnosis was 43 years, and, 83% of these individuals were in remission. During a median follow up of 13 years—half followed for longer, half followed for less time—the researchers noted 133 deaths, more than the 54 that had been anticipated in this patient population. From this data,1 Dr. Ragnarsson and his team calculated that people with Cushing's disease were about 2.5 times more likely to die than the general population. The most common reason, with more than a 3-fold increased risk, was attributed to events associated with cardiovascular disease, encompassing both heart disease and stroke. This group also appeared to have a higher risk of death from infectious and respiratory diseases, and conditions related to gastrointestinal problems. Fortunately, just being in disease remission helps to reduce the risk of all-cause mortality,1 the researchers' report, with both men and women whose Cushing’s disease is well-managed having a two-fold lower risk of death during the follow-up period.1 Those in remission who were receiving growth hormone had an even lower risk of death than those on other forms of treatment. In addition, the researchers looked at the 55 patients with Cushing’s disease who were in remission and also had diabetes, finding that their risks remained the same. In other words, despite a strong relationship between diabetes and increased heart disease, the risks of death were not increased in this group of patients.1 In considering the impact that treatments may have, the researchers found: 3 in 4 of these patients (75%) had undergone pituitary surgery 28% had undergone radiotherapy 1 in 4 (24%) had had both adrenal glands removed Those who had their adrenal glands removal experienced a 2.7-fold higher risk of death, while those who were treated with radiotherapy or had pituitary surgery did not have an increased risk associated with cardiovascular events. When glucocorticoid therapy was added, it did not affect results, according to Dr. Ragnarsson and his research team. Bottom line? "Even though patients in remission have a better prognosis than patients not in remission, they still have more than a 2-fold increased mortality [risk]," he says. The study, he says, is the first to uncover a high rate of death from suicide in Cushing's patients. It has been reported before, but the numbers found in this study were higher than in others. The findings, he says, emphasize the importance of treating Cushing's with a goal of remission. Ongoing surveillance and management are crucial, he says. "Also, evaluation and active treatment of cardiovascular risk factors and mental health is of utmost importance," Dr. Ragnarsson tells EndocrineWeb. Remission Reduces But Doesn't Eliminate Serious Risks The study findings underscore the message that ''the priority for patients is to achieve biochemical remission," says Tamara L. Wexler, MD, PhD, director of the NYU Langone Medical Center Pituitary Center, in reviewing the findings for EndocrineWeb. "One question raised by the study findings is whether patients listed as being in remission were truly in (consistent) remission," Dr. Wexler says. "One or more of several testing methods may have been used, and the data were based on medical record reviews so we can’t be certain about the status of these patients’ remission. In addition, we don’t know how much excess cortisol patients were exposed over time, which may change their risks.'' I have another concern about the findings, she says. While the method of analysis used in the study suggests that the length of time from diagnosis to remission is not associated with increased death risk, ''it may be that the total exposure to excess cortisol—the amplitude as well as duration—is related to morbidity [illness] and mortality [death] risk.'' And, she adds, any negative effects experienced by patients with Cushing’s disease may be reduced further as remission status continues. In addition, Dr. Wexler considers the authors' comments that sustained high cortisol levels may impact the cardiovascular system in a way that is chronic and irreversible ''may be overly strong." She believes that the total cortisol exposure and the duration of remission may both play important roles in patients' ongoing health. She does agree, however, with the researchers' recommendation of the need to treat heart disease risk factors more aggressively in patients with a history of Cushing's disease. Equally important, is for patients to be warned that there is an increased concern about suicide, she says, urging anyone with Cushing’s disease to raise all of these concerns with your health practitioner. Overall, the study findings certainly suggest that it is important for you to know that if you have Cushing’s syndrome, you are at increased risk for not just heart disease but also mental health disorders and other ailments than the general population, she says, and that the best course of action is to work closely with your doctor to achieve remission and stick to your overall treatment plan. Steps to Take to Reduce Your Risks for Heart Disease and Depression Dr. Ragnarsson suggests those with Cushing's disease make adjustments as needed to achieve the following risk-reducing strategies: Be sure your food choices meet the parameters of a heart-healthy diet You are getting some kind of physical activity most every day You see your doctor at least once a year to have annual checks of your blood pressure, blood sugar, and other heart disease risk factors. For those of you receiving cortisone replacement therapy, you should be mindful of the need to have a boost in your medication dose with your doctors' supervision when you're are sick or experiencing increased health stresses. From https://www.endocrineweb.com/news/adrenal-disorders/61675-cushings-disease-stresses-your-heart-your-mental-health
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A patient with depression developed Cushing’s syndrome (CS) because of a rare ACTH-secreting small cell cancer of the prostate, a case study reports. The case report, “An unusual cause of depression in an older man: Cushing’s syndrome resulting from metastatic small cell cancer of the prostate,” was published in the “Lesson of the Month” section of Clinical Medicine. Ectopic CS is a condition caused by an adrenocorticotropic hormone (ACTH)-secreting tumor outside the pituitary or adrenal glands. The excess ACTH then acts on the adrenal glands, causing them to produce too much cortisol. Small cell cancer is more common in older men, those in their 60s or 70s. Sources of ectopic ACTH synthesis arising in the pelvis are rare; nonetheless, ACTH overproduction has been linked to tumors in the gonads and genitourinary organs, including the prostate. Still, evidence suggests there are less than 30 published cases reporting ectopic CS caused by prostate cancer. Researchers from the Southern Adelaide Local Health Network and the Royal Adelaide Hospital in Australia described the case of an 84-year-old man who complained of fatigue, back pain, and lack of appetite. Blood tests revealed mildly elevated prostate-specific antigen (PSA) and creatinine levels, which could indicate the presence of prostate cancer and impaired kidney function, respectively. The patient had a history of locally invasive prostate cancer even though he didn’t experience any symptoms of this disease. Ultrasound examination showed an enlarged prostate plus obstructed ureters — the tubes that carry urine from the kidney to the bladder. To remove the obstruction, doctors inserted a thin tube into both ureters and restored urine flow. After the procedure, the man had low levels of calcium, a depressed mood, and back pain, all of which compromised his recovery. Imaging of his back showed no obvious reason for his complaints, and he was discharged. Eight days later, the patient went to the emergency room of a large public hospital because of back pain radiating to his left buttock. The man also had mild proximal weakness on both sides. He was thinner, and had low levels of calcium, high blood pressure and serum bicarbonate levels, plus elevated blood sugar. In addition, his depression was much worse. A psychiatrist prescribed him an antidepressant called mirtazapine, and regular follow-up showed that his mood did improve with therapy. A computed tomography (CT) scan revealed a 10.5 cm tumor on the prostate and metastasis on the lungs and liver. Further testing showed high serum cortisol and ACTH levels, consistent with a diagnosis of Cushing’s syndrome. But researchers could not identify the ACTH source, and three weeks later, the patient died of a generalized bacterial infection, despite treatment with broad-spectrum antibiotics. An autopsy revealed that the cancer had spread to the pelvic sidewalls and to one of the adrenal glands. Tissue analysis revealed that the patient had two types of cancer: acinar adenocarcinoma and small cell neuroendocrine carcinoma — which could explain the excess ACTH. Cause of death was bronchopneumonia, a severe inflammation of the lungs, triggered by an invasive fungal infection. Investigators believe there are things to be learned from this case, saying, “Neither the visceral metastases nor aggressive growth of the pelvic mass noted on imaging were typical of prostatic adenocarcinoma. [Plus], an incomplete diagnosis at death was the precipitant for a post-mortem examination. The autopsy findings were beneficial to the patient’s family and treating team. The case was discussed at a regular teaching meeting at a large tertiary hospital and, thus, was beneficial to a wide medical audience.” Although a rare cause of ectopic ACTH synthesis, small cell prostate cancer should be considered in men presenting with Cushing’s syndrome, especially in those with a “mystery” source of ACTH overproduction. “This case highlights the importance of multidisciplinary evaluation of clinical cases both [before and after death], and is a fine example of how autopsy findings can be used to benefit a wide audience,” the researchers concluded. https://cushingsdiseasenews.com/2018/10/16/rare-prostate-cancer-prostate-associated-cushings-syndrome-case-report/
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Shianne was a Cushing's Survivor who had just published a book, Be Your Own Doctor After 17 years as a personal trainer, I ran into health problems of my own, eventually having a name put to it…“Cushing’s Syndrome,” a rare adrenal disease. Tumors were growing on my adrenal glands over-producing Cortisol, your stress hormone. With 24/7 false fight-or-flight stress signals, the body goes haywire, producing horrific side effects such as weight gain around the midsection and back of neck, diabetes and blood sugar deregulation, inflammation, muscle deterioration, frail bones, hair loss, poor immunity, infertility, moonface, buffalo hump, extreme fatigue, brain fog, confusion, severe anxiety/depression and chemical imbalances. Being constantly diagnosed as “healthy” caused me to be told, when I was finally diagnosed correctly, that I had maybe five years to live. Misdiagnosis can be a killer.… It is now my personal mission and obligation to help those suffering from any chronic illness that steals your joy, and bring awareness to Endocrine Disorders. From my journey through Cushing’s to Addison’s to recovery—from triathlete to barely being able to dress myself and finally to recovering into a stronger person I never knew I was. Her obituary can be read here. https://youtu.be/5qXYrm6OqYk Shianne F. Lombard-Treman May 03, 1977 - March 28, 2018
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A friend of mine, who is a nurse, randomly asked if I had ever been diagnosed with Cushing's Syndrome. I told him no, I'd never heard of it before, and started looking into it. I probably shouldn't have, because now I am paranoid. Some of my symptoms match, but I don't have the main symptoms. I'm fairly thin, with pale skin which bruises and tears easily. I have been diagnosed with depression and anxiety which lead to panic attacks, and the medications I take don't seem to work for me. I have a naturally round face, or so I think, that is almost always red with acne on my cheeks and neck. I don't think I'm gaining weight, or have a hump between my shoulders. I'm afraid to think I have something so severe just because I want to feel better from this crippling depression that has taken 4 years of my life from me. Do I sound like a Cushie?
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I first became aware of Bill on November 6, but now that I know about him, I am pretty sure he officially arrived during the summer of 2012. Since then, I suffered from depression, acne, menstrual problems, 30lb weight gain (while training for a marathon), and high blood pressure. Best of all, Bill has taken up residence on the back of my neck and created a little colony on my belly too. I always been pretty healthy (except for hypothyroidism) but in the last year, I had seen several different doctors for all of the weird things that have been happening to me. A gynecologist and dermatologist both suggested my menstrual and acne problems were likely hormonal and happening because I was probably going through perimenopause (I was 40 at the time). A psychiatrist put me on Effexor for depression and a beta-blocker for anxiety (I jump a foot when the phone would ring or someone would knock on my office door). All of these treatments seemed completely reasonable to me and they helped. It never occurred to me or anyone else they could be related. And all potentially explained why I kept gaining weight, despite not changing my diet and exercise (5-6 days a week) regime. Who knew hitting your 40s was going to be this rough? I started to really slow down on my runs - 2 to 3 minutes per mile slower than before. Maybe it was the weight gain that was making running harder, maybe it was the unusually hot and humid summer. I kept waiting for my running to get back to normal. But it never did. Every day it was a struggle to run. It was something I used to love so much - it was my way of working through stress. Now, it just made me feel bad. When I went to my regular endocrinologist in July for my annual thyroid check-up, he discovered my TSH was "way off" - and a little light went on. That's why I felt so crappy this year! I recounted my symptoms to Endo 1 (whom I had been seeing for 7 years). He thought I must be "very sensitive" to changes in hormones to have such a large reaction to the drop in TSH but hey, you never know. My Synthroid does was adjusted and I kept waiting to feel better. But I just kept getting worse. At my follow-up appointment in October, Endo 1 (who was with a medical student) told me my hormone levels were perfect and my face fell. He said I looked like I wanted a different answer. I explained that I felt worse and was having very troubling symptoms now. I run the week before and two miles in developed an excruciating headache, blurry vision and unsteadiness that stopped me in my tracks. I had to sit down for 30 minutes before the symptoms subsided and I could walk back to my car. I haven't run since. He started standing up, with the medical student in tow, and told me "this is not an endocrine problem - you should talk to your PCP and go see a cardiologist." That was that. I found a great cardiologist that deals with athletes, Dr. B. I was supposed to run the Philly marathon in November and so I tried to get his nurse to squeeze me onto his schedule in early November so I could figure out if there was something wrong with my heart. I had a stress test at his lab which came out completely normal. However, my blood pressure was very high. He told me that my heart was fine but something was very wrong for my blood pressure to be so high. I had mentioned to him that I had high BP readings at the various doctor's offices I had visited over the year - but I was always told "you are young and healthy, your BP is just high because you are in seeing the doctor today" (which for the record is ridiculous - it is hard to stress me out and a visit to the doctor is certainly not enough to do it). After reviewing my records and giving me a physical exam, he came back and told me he suspected I had Cushing's. He started some lab work to try and test for it too - two 24 hour UFC's and a dexamethasone suppression test. I had never heard of Cushing's, but my symptoms fit to a T. And as I read about "buffalo humps" and reached up to feel my neck, I realized I had known about Bill for some time. The cardiologist was so wonderful. He told me. "This is an endocrine issue, not a cardiac issue. But I am going to keep seeing you until you are better and I am going to help you navigate through the system." I felt very happy and relieved when I left his office. There was something wrong and it had a name. Now, I would just have a couple of tests, see my endocrinologist and go back to my normal life. If only life were so easy....
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Even after successful treatment, patients with Cushing’s disease who were older when diagnosed or had prolonged exposure to excess cortisol face a greater risk of dying or developing cardiovascular disease, according to a recent study accepted for publication in The Endocrine Society’s Journal of Clinical Endocrinology & Metabolism (JCEM). Cushing’s disease is a rare condition where the body is exposed to excess cortisol – a stress hormone produced in the adrenal gland – for long periods of time. Researchers have long known that patients who have Cushing’s disease are at greater risk of developing and dying from cardiovascular disease than the average person. This study examined whether the risk could be eliminated or reduced when the disease is controlled. Researchers found that these risk factors remained long after patients were exposed to excess cortisol. “The longer patients with Cushing’s disease are exposed to excess cortisol and the older they are when diagnosed, the more likely they are to experience these challenges,” said Eliza B. Geer, MD, of Mount Sinai Medical Center and lead author of the study. “The findings demonstrate just how critical it is for Cushing’s disease to be diagnosed and treated quickly. Patients also need long-term follow-up care to help them achieve good outcomes.” The study found cured Cushing’s disease patients who had depression when they started to experience symptoms of the disease had an elevated risk of mortality and cardiovascular disease. Men were more at risk than women, a trend that may be explained by a lack of follow-up care, according to the study. In addition, patients who had both Cushing’s syndrome and diabetes were more likely to develop cardiovascular disease. The study examined one of the largest cohorts of Cushing’s disease patients operated on by a single surgeon. The researchers retrospectively reviewed charts for 346 Cushing’s disease patients who were treated between 1980 and 2011. Researchers estimated the duration of exposure to excess cortisol by calculating how long symptoms lasted before the patient went into remission. The patients who were studied had an average exposure period of 40 months. The findings may have implications for people who take steroid medications, Geer said. People treated with high doses of steroid medications such as prednisone, hydrocortisone or dexamethasone are exposed to high levels of cortisol and may experience similar conditions as Cushing’s disease patients. “While steroid medications are useful for treating patients with a variety of conditions, the data suggests health care providers need to be aware that older patients or those who take steroid medications for long periods could be facing higher risk,” Geer said. “These patients should be monitored carefully while more study is done in this area.” From http://www.medicalnewstoday.com/releases/256284.php
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(HealthDay News) – A number of factors, including the duration of glucocorticoid exposure, older age at diagnosis, and preoperative adrenocorticotropic hormone (ACTH) concentration, are associated with a higher risk of mortality in patients treated for Cushing's disease (CD), according to research published online Feb. 7 in the Journal of Clinical Endocrinology & Metabolism. In an effort to identify predictors of mortality, cardiovascular disease, and recurrence with long-term follow-up, Jessica K. Lambert, MD, of the Mount Sinai Medical Center in New York City, and colleagues performed a retrospective chart review of 346 patients with CD who underwent transsphenoidal adenectomy. The researchers found that the average length of exposure to glucocorticoids was 40 months. The risk of death was higher for those patients who had a longer duration of glucocorticoid exposure, older age at diagnosis, and higher preoperative ACTH concentration. For patients who achieved remission, depressed patients had a higher risk of death. The risk of cardiovascular disease was highest for men, older people, and those with diabetes or depression. "Our study has identified several predictors of mortality in patients with treated CD, including duration of exposure to excess glucocorticoids, preoperative ACTH concentration, and older age at diagnosis. Depression and male gender predicted mortality among patients who achieved remission," the authors write. "These data illustrate the importance of early recognition and treatment of CD. Long-term follow-up, with management of persistent comorbidities by an experienced endocrinologist, is needed even after successful treatment of CD." Abstract Full Text (subscription or payment may be required)
