cushing syndrome and its manifestations.pptx

Case study

1. Personal history S.M.I., 46 years old female patient, mother of 6 children, the youngest is 7 years old, born in El-Fayoum, and living in El-Marg, worked as a worker, resigned 4 months ago due to her current illness, no special habits of medical importance.

2. Complaint Easy fatigue & asthenia

3. Present History Over the past year, the patient noticed that her face gradually became more full & rounded, with increase in the body hair especially at the face. Also the patient noticed gradual gaining of weight, central more than peripheral; (abdomen, supraclavicular, & back of the neck).

4. Also, the patient complained of gradually increasing easy fatigability & generalized body aches (for which she took NSAIDs) , up to quitting her job 4 months ago. There was no muscle weakness, difficulty in climbing stairs, or rising from sitting position.

5. 9 months ago, the patient had irregular menstrual cycles 4 months ago she developed amenorrhea There is no history of headache, blurring of vision, or projectile vomiting. There is no history of nipple discharge. There is no history of skin pigmentation. There is no history of stria, easy bruising, delayed wound healing or recurrent infections.

6. There is no history of palpitations, fever, or diaphoretic episodes. There is no history of dyspnea, orthopnea, PND, cough or chest pain. There is no history of other system affection.

7. The patient sought medical advice and many investigations were done for her, she was discovered to be hypertensive, & there was cortisol secreting left suprarenal mass. She was referred to NCI 4 months ago, she was candidate for surgery, but surgery was postponed due to elevated liver enzymes.

8. She was prescribed Amlodipine 5mg/valsartan 160mg for hypertension & she was referred to NHI for following liver condition. 1 week ago, liver enzymes were nearly normal, & she was referred to our endocrinology clinic for perioperative recommendations.

9. Past history No history of previous operations,TB, RHD, or drug allergy Family history Irrelevant .

10. Examination

11. General examination The patient was fully conscious, with cushingoid appearance Weight: 81 kg Height: 156 cm BMI: 33 kg/m2 Waist to hip ratio: 1.2

12. Vital signs Pulse: 80 beats/minute, regular, average pulse volume, equal on both sides, with intact peripheral pulsations. Blood pressure: 140/90 mmHg with no postural drop . Respiratory rate: 18 /minute. Temperature: 37.1 .

13. Head & Neck Plethoric, moon face, buffalo hump Increased lanugo facial hair, No acne or hair line recession No acanthosis nigricans or mucosal pigmentation No thyroid enlargement No malar rash, oral ulcers Neck veins are not congested . Carotid pulsations are equally felt Trachea is central

14. Extremities Thin extremities with thin skin fold No stria or excessive pigmentation No rash, petechiae or ecchymosis. No clubbing or flat nails. No palmer erythema. No flapping tremors. No Lower limb edema

15. Cardiac examination Inspection and palpation: No scars or dilated veins No precordial bulge The apex is localized in the left fifth space MCL, with no thrill . No palpable pulsations. Auscultation: Normal S1 & S2 No additional sounds

16. Chest examination Inspection: Normal shaped chest, symmetrical, no dilated veins or scars. No striae or excessive hair Palpation: Normal chest expansion, central trachea, no tenderness Normal TVF with no palpable rub or rhonchi. Percussion: Normal percussion note . The upper border of the liver is in the right 5 th space MCL, Auscultation: Normal vesicular breathing. No additional sounds.

17. Abdominal examination Inspection Abdomen moves freely with respiration Generalized abdominal distention, more on left side No striae, scars or dilated veins . Normal hair distribution.

18. Abdominal examination Superficial Palpation No tenderness or rigidity Deep Palpation Abdominal mass in left hypochondrial & left lumbar region, 15x13 cm oval in shape, with firm consistency & smooth surface. Percussion No Ascites detected clinically. Auscultation Normal intestinal sounds

19. Back : No tenderness or deformity Lymph node examination: N ormal Neurological examination: Speech: N ormal Cranial nerves: N ormal with normal confrontation test Motor examination: no wasting, normal tone, power & reflexes Normal superficial & deep sensations Normal gait

20. Investigations

21. HB 12 g/dl MCV 87 fL MCH 28 Pg Plt 238 10ˆ3/UL TLC 9.5 10ˆ3/UL CBC

22. 26/6 11/8 8/9 18/9 Creat 0.8 mg/dl UA 5.2 mg/dl Na 140 143 mmol/dl K 3.7 4 mmol/dl Ca corrected 9.5 mg/dl T.Bil 0.17 0.3 mg/dl Alb 3.5 g/dl ALT 121 340 250 100 U/L AST 88 202 171 65 U/L ALP 114 U/L Chemistry :

23. Chemistry : FBG 90 Mg/dl PPG 110 Mg/dl TGs 170 Mg/dl CHOL 195 Mg/dl LDL 136 Mg/dl HDL 45 Mg/dl TIBC 292 Mg/dl

24. PT 13.9 PC 90% INR 1.07 Coagulation profile Negative HBs Ag Negative HCV Ab

25. Cortisol 9 am 26.9 ug/dl 4.3-22.4 ACTH (am) 7.34 pg /mL Less than 65 Cortisol 9 pm 35.88 ug/dl 3.1-16.7 24 hr urinary Cortisol 342 ug/24hrs 21 - 292 Dexamethasone Suppression Test  Serum Cortisol 9 am 29.76 ug/dl 4.3 - 22.4 Serum Cortisol 9 pm 32.47 ug/dl 3.1 - 16.7 Serum Cortisol (9 am, after dose) 31.07 ug/dl

26. Metanephrine, Normetanephrine & VMA in Urine Normetanephrine 131.6 ug/24hrs Less than 527 Metanephrine 42.48 ug/24hrs Less than 302 VMA 4.02 mg/24hr Up to 13.6

27. CT chest, abdomen & chest with contrast A left suprarenal neoplastic lesion with macrolbulated outline contour measuring 12.5 x 12.3 x 16 cm is seen indenting abutting the left kidney upper pole . Few regional pre-/para-aortic LNs are noted, largest measuring 23x18 mm, no intranodal calcification nor cystic breakdown changes Patent and enhancing left renal vein and IVC

28. Left adrenalectomy & nephrectomy were done 1weak ago.