Hypercortisolism in a Patient Affected By Anorexia Nervosa

Presentation Number: SUN-0779
Date of Presentation: June 22nd, 2014

Caterina Policola*, Chiara Maria Assunta Cefalo, Simona Moffa, Barbara Altieri, Vinsin Alice Sun, Alfredo Pontecorvi and Silvia Della Casa
Endocrinologia e Malattie del Metabolismo, Università Cattolica del Sacro Cuore, Rome, Italy

Abstract

Background: Anorexia Nervosa (AN) is a psychiatric disorder, affecting about 1 in 250 females,  usually starting in adolescence. It is characterized by self-induced weight loss, body image distortion and obsessive fear of gaining weight. Patients affected by AN have a Pseudo-Cushing’ s Syndrome (PCS); food deprivation hypoglicemia is a possible mechanism for an increased activation of the HPA axis. PCS is characterized by a high ACTH and cortisol levels, elevated urinary free cortisol excretion, not dexamethasone (Dex) suppressed  cortisol, and elevated nocturnal cortisol secretion. The lack of Cushing’s symptoms is due to resistence to cortisol. Clinical Case: We report a case of a 28 year-old woman who referred to us for peripheral oedemas, a 5-year history of restrictive AN, on psychiatric treatment and amenorreha. On examination she had peripheral and lower limb oedema, ecchymosis on her legs. Weight  was 47 Kg and BMI 17.8 Kg/m2 (on weight recovery). Liver and renal functions were normal, she had not heart failure, and albumina and proteins serum levels were normal. Severe osteoporosis was recorded. Hormonal values were: IGF-1 <25 ng/ml (v.n.: 80-330), TSH 0.79 mcUI/ml (0.35-2.8), fT3 1.5 pg/ml (2.3-4.2), fT4 10 pg/ml (8.5-15.5), LH <0.5 mcUI/ml (2.5-11), FSH <0.5 mcUI/ml (2.5-15), 17-betaEstradiol <15 pg/ml, Cortisol 357 ng/dl (60-220), Midnight cortisol 281 ng/dl, 1 mg Dex suppression test Cortisol  298 ng/ml, 24h Cortisoluria 1065 mcg/24 h (<70). Her Hormonal state was compatible with AN patient’s biochemical features and PCS, but she had basal ACTH: <5 pg/ml (10-55). An Abdomen Ultrasound showed an iso-hyperecogenic, solid nodule on the right adrenal gland. 8 mg Dex suppression test: cortisol was 260 ng/dl and ACTH <5 pg/ml. The Abdominal CT confirmed the presence of 3.2 x 2.2 cm  right adrenal gland mass, ipodense (likely an adrenal  adenoma. She underwent right retroperitoneoscopic adrenalectomy under pre and peri-operative protection with stress-dose Hydrocortison replacement. Histological examination confirmed the adrenal adenoma. The psychiatric disease improved after the operation. She was started on Hydrocortison and she had been on therapy for 1 year, because persistent suppression of the Pituitary-Adrenal axis. After normalization of basal ACTH and cortisol and Short Synacthen Test, Hydrocortison therapy was discontinued. The long-term follow-up revealed complete recovery of eating disorder with resumption of periods. Actually her pituitaty-adrenal axis is normal, she is not on therapy. Conclusion: The differential diagnosis between Cushing Syndrome and PCS in AN patients can be extremely difficult and it represent a challenge for the clinicians.

 

Nothing to Disclose: CP, CMAC, SM, BA, VAS, AP, SD