DOI: https://doi.org/10.14710/halal.v%25vi%25i.9247

Cushing’s syndrome manifesting as chronic insomnia caused by adrenal cortical adenoma with incidental pituitary microadenoma: a case report

Dr. Kariadi Central General Hospital, Indonesia

Received: 23 Oct 2020; Revised: 13 Apr 2021; Accepted: 16 Apr 2021; Available online: 30 Apr 2021; Published: 30 Apr 2021.
Open Access Copyright (c) 2021 Journal of Biomedicine and Translational Research

Citation Format:
Abstract

Background: Cushing’s syndrome is condition caused by excessive glucocorticoid with insomnia as one of its neuropsychiatric manifestation. Cushing’s syndrome may be caused by excessive adrenocorticotropin hormone (ACTH-dependent), for example from ACTH producing pituitary tumors, or by overproduction of cortisol by adrenocortical tumors. In this report, we presented a case with Cushing’s syndrome manifesting as chronic insomnia with adrenal cortical adenoma and pituitary microadenoma.

Case presentation: A 30-year-old woman was consulted from the Neurologic Department to the Internal Medicine Department with the chief complaint of insomnia and worsening headache since 6 months prior to the admission. She had undergone head MRI and abdominal CT scan previously and was found to have both pituitary microadenoma and left adrenal mass. From the physical examination she had clinical signs of Cushing’s syndrome like Cushingoid face and purplish striae on her stomach. Midnight cortisol serum examination was done initially and showed high level of cortisol. High dose dexamethasone suppression test or DST (8 mg overnight) was later performed to help determine the main cause of Cushing’s syndrome. The result failed to reach 50% suppression of cortisol serum, suggestive that the Cushing’s syndrome was not ACTH-dependent from the pituitary but potentially from overproduction of cortisol by the left adrenal mass. Therefore, left adrenalectomy was performed and the histopathological study supported the diagnosis of adrenal cortical adenoma.

Conclusion: Chronic insomnia is a very important symptoms of Cushing’s syndrome that should not be neglected. The patient had both microadenoma pituitary and left adrenal mass thus high dose DST test (8 mg overnight) needed to be performed to differentiate the source of Cushing’s syndrome. The result showed only little suppression therefore the pituitary microadenoma was not the source of Cushing’s syndrome and more suggestive from the adrenal etiology.

Fulltext View|Download
Keywords: Cushing’s syndrome; insomnia; adrenal cortical adenoma; pituitary microadenoma; dexamethasone suppression test

Article Metrics:

Article Info
Section: Case Reports
Language : EN
Recent articles
Effect of Aerobic Exercise on Left Ventricular Connexin43 Expression and Distribution in Juvenile and Young Adult Rats The Evaluation of Parental Acceptance Towards Children with Sex Chromosomal Disorders of Sex Development Using A Mixed-Method B- Acute Lymphoblastic Leukemia L2 In Second Trimester of Pregnancy Cushing’s syndrome manifesting as chronic insomnia caused by adrenal cortical adenoma with incidental pituitary microadenoma: a case report Fragmentomic cfDNA Patterns in Noninvasive Prenatal Testing and Beyond Prerequisite Evaluation of Anaerobic Settings for Gut Microbiome Functional Studies More recent articles
  1. Stratakis CA. Cushing syndrome caused by adrenocortical tumors and hyperplasias (corticotropin- independent Cushing syndrome). Endocr Dev [Internet]. 2008;13:117—132. Available from: https://www.karger.com/article/Abstract/134829
  2. Raff H, Sharma ST, Nieman LK. Physiological basis for the etiology, diagnosis, and treatment of adrenal disorders: Cushing’s syndrome, adrenal insufficiency, and congenital adrenal hyperplasia. Compr Physiol [Internet]. 2014 Apr;4(2):739–69. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/cphy.c130035
  3. Starkman MN. Neuropsychiatric Findings in Cushing Syndrome and Exogenous Glucocorticoid Administration [Internet]. Vol. 42, Endocrinology and Metabolism Clinics of North America. 2013. p. 477–88. Available from: https://www.endo.theclinics.com/article/S0889-8529(13)00049-2/abstract
  4. Nieman LK, Biller BMK, Findling JW, Newell-Price J, Savage MO, Stewart PM, et al. The Diagnosis of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab [Internet]. 2008;93(5):1526–40. Available from: https://academic.oup.com/jcem/article/93/5/1526/2598096
  5. Feelders R, Sharma S, Nieman L. Cushing’s syndrome: epidemiology and developments in disease management. Clin Epidemiol [Internet]. 2015 Apr 17 [cited 2019 Mar 7];7:281. Available from: https://www.dovepress.com/cushing39s-syndrome-epidemiology-and-developments-in-disease-managemen-peer-reviewed-fulltext-article-CLEP
  6. Ergin A, Hamrahian A, Kennedy L, Gupta M. Overnight High Dose Dexamethasone Suppression Test—8 mg. In: The Cleveland Clinic Manual of Dynamic Endocrine Testing. 2015. p. 31–4
  7. Esfahanian F, Kazemi R. Overnight dexamethasone suppression test in the diagnosis of Cushing’s disease. Acta Med Iran. 2010;48(4):222–5
  8. Lindholm J, Juul S, Jørgensen JOL, Astrup J, Bjerre P, Feldt-Rasmussen U, et al. Incidence and Late Prognosis of Cushing’s Syndrome: A Population-Based Study. J Clin Endocrinol Metab [Internet]. 2001;86(1):117–23. Available from: https://academic.oup.com/jcem/article/86/1/117/2841121
  9. Ross EJ, Linch DC. Cushing’s syndrome-killing disease: discriminatory value of signs and symptoms aiding early diagnosis. Lancet (London, England) [Internet]. 1982 Sep;2(8299):646–9. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0140673682927490
  10. Balbo M, Leproult R, Van Cauter E. Impact of Sleep and Its Disturbances on Hypothalamo-Pituitary-Adrenal Axis Activity. Suchecki D, editor. Int J Endocrinol [Internet]. 2010;2010:759234. Available from: https://doi.org/10.1155/2010/759234
  11. Brown ES, Rush AJ, McEwen BS. Hippocampal remodeling and damage by corticosteroids: implications for mood disorders. Neuropsychopharmacology [Internet]. 1999 Oct;21(4):474—484. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0893133X99000548
  12. Pereira AM, Tiemensma J, Romijn JA. Neuropsychiatric disorders in Cushing’s syndrome. Neuroendocrinology [Internet]. 2010;92 Suppl 1:65—70. Available from: https://www.karger.com/Article/Abstract/314317
  13. Bourdeau I, Bard C, Noël B, Leclerc I, Cordeau M-P, Bélair M, et al. Loss of Brain Volume in Endogenous Cushing’s Syndrome and Its Reversibility after Correction of Hypercortisolism. J Clin Endocrinol Metab [Internet]. 2002;87(5):1949–54. Available from: https://academic.oup.com/jcem/article/87/5/1949/2846461
  14. Patronas N, Bulakbasi N, Stratakis CA, Lafferty A, Oldfield EH, Doppman J, et al. Spoiled Gradient Recalled Acquisition in the Steady State Technique Is Superior to Conventional Postcontrast Spin Echo Technique for Magnetic Resonance Imaging Detection of Adrenocorticotropin-Secreting Pituitary Tumors. J Clin Endocrinol Metab [Internet]. 2003;88(4):1565–9. Available from: https://academic.oup.com/jcem/article/88/4/1565/2845241
  15. Hall WA, Luciano MG, Doppman JL, Patronas NJ, Oldfield EH. Pituitary magnetic resonance imaging in normal human volunteers: occult adenomas in the general population. Ann Intern Med [Internet]. 1994;120(10):817–20. Available from: https://www.acpjournals.org/doi/abs/10.7326/0003-4819-120-10-199405150-00001
  16. Liddle GW. Tests of Pituitary-Adrenal Suppressibility in the Diagnosis of Cushing’s Syndrome. J Clin Endocrinol Metab [Internet]. 1960;20(12):1539–60. Available from: https://doi.org/10.1210/jcem-20-12-1539

Last update:

No citation recorded.

Last update:

No citation recorded.