Cushing Syndrome VS. Metabolic Syndrome

Presentation Number: MON 408
Date of Presentation: April 3rd, 2017

Antonio Selman-Geara*1, Luis N. Novas-Aquino2, Alejandro Uribe-Peguero2, Jose M. Paliza3, Antonio Selman-Almonte1 and Antoine Selman-Fermin4
1Universidad Central Del Este, Santo Domingo, Dominican Republic, 2Universidad Central del Este, Santo Domingo, Dominican Republic, 3Diagnostica, S.A., Santo Domingo, Dominican Republic, 4Einstein Medical Center Philadelphia, Philadelphia, PA


CASE: Female, born on 12/11/1978, referred to us by cardiologist and psychiatrist due to stigma of Cushing's Syndrome and/or Metabolic Syndrome and mental illness as depression. Family history: father cardiac arritmia, mother benign multiple colloids thyroid nodules, 4 siblings (1 died). Her husband is fine. One daughter born on 1/19/2010 is fine. Late onset of menarch at 18 but at 15 was induced by oral HR. She was diagnosed as PCOs, her pregnancy with GD, preeclampsia, NAFLD, thyroid nodules. After cesarean section lactation was very scant. She complains of (1-6)weight gain, moon face, abdominal obesity, cervical hump, acanthosis nigricans, barbel hirsutism, mother-of-pearl abdominal and chest striae, high blood pressure, high blood sugar, slimming inferior extremity. TESTS: (11/14/2013) Cortisol a.m. 21.26 ug/d (NR:6.2-19.4 ug/dL) OGTT basal 144, 1h 331, 2hs 316, 3hs 227 mg/dL. HbA1c7.9%, CRP 12, normal lipids profile, 24hs urinary cortisol 133.5 (NR12.9-253 ug/24hs) (11/18/2014) basal blood glucose 158, 2hs pp glucose 309.1 Chest X ray nl result, a.m. Cortisol 5.7 (NR:5.5-20 ug/dL) p.m. Cortisol 2.35 (NR:2.0-10.0 ug/dL) PRL 5.8 (NR:3.4-30.9 ng/mL) TSH 1.57 (NR: 0.38-4.7 uIU/mL) 12/5/2014 (7-8)Abdominal MRI nl 2/4/2015 Cortisol, Salivary 0.09 (NR:23 hs -0.09) (2/5/2015) Cortisol, Salivary 0.07 (NR:-0.09 mcg/dL) (2/6/2015) Cortisol Salivary 0.06 (NR:-0.09 mcg/dL) (all at 23 hs) Basal Cortisol 8.45 (NR:5-25 ug/dL) (3/3/2015) basal blood glucose 163 (NR:60-100 mg/dL) basal insulin 39.6 (NR:0.0-29.1 mIU/mL) 2 hs pp blood glucose 211.4 (NR:-140 mg/dL) 2hs pp insulin 298 (mIU/mL) basal C peptide 7.19 (NR:0.9-7.1 ng/mL) 2hs pp C peptide 16.8 ng/mL creatinine 0.82 (NR:0.6-1.2 mg/dL) midnight plasma cortisol 2.23 (NR:2.5-12.5 ug/dL)1/25/2015: Cortisol, free, Urine 70.9 mcg/24h (NR:4.0-50.0) 4/6/2015 (9-10)Pituitary MRI+gadolinium normal limit 6/1/2016/ 1 mg DST basal Cortisol 8.06 ug/dL Cortisol 8hs after 1 mg dx 1.10 ug/dL basal blood glucose 162.6 (NR:60-100 mg/dL) basal insulin 40.6 (NR:0.0-29.1 mIU/mL) 2hs pp blood glucose 305.2 (NR:-140 mg/dL) 2hs pp insulin 253.0 mIU/mL Cortisol, Salivary 0.04 (NR:23 h -0.09 mcg/dL) Creatinine, 24-h urine 2.16 (NR:0.63-2.50 g/24h) Cortisol free, 24 hr urine 63.6 (NR:4.0-50 mcgs/24h). 6/21/2016: 2.1x1.2 cm Thyroid nodule biopsy shows microfolicular lesion with cytologic atypia as a folicular neoplasia (Bethesda IV).

CONCLUSIONS: This case represents a clinical challenge for any physician. The physical aspect of the patient makes a clear idea of the Cushing’s Syndrome, but we have only two tests in favour: 24 hs urinary free Cortisol twice (1/25/2015 & 6/6/2016). Pituitary and adrenal gland images are normal, the metabolic status is similar for both disorders as Diabetes and high blood pressure, finally we conclude that it is more propense to think that the case involves a severe Metabolic Syndrome more than a Cushing.


Nothing to Disclose: AS, LNN, AU, JMP, AS, AS