MON-411 Psychological Disturbance And Weight Gain; Early Identification Of Cushing’S Disease In A Teenage Patient.

Abstract

Abstract Cushing’s disease is rare in adolescents, and its clinical presentation differ from those in adults. Psychological problems, such as depression and behavioral changes, may be the major complaints in adolescents with Cushing’s disease. Our patient presented with such problem as initial symptoms. Clinical case: A 19-year-old woman without any significant past medical history presented for evaluation of excessive fatigue, depressed mood, emotional lability, irritability, and sleep disturbances. On further questioning, she reported weight gain of 40 lbs in the last 1 year. She attributed this to lack of physical activity since high school graduation and also being on OCP for 6 months ago. On physical examination, she weighed 73.9 kg (163 lbs.) with a height of 172 cm and a BMI 24.99 kg/m². The rest of the physical examination revealed mild facial acne and purple striae on thighs. Moon face, buffalo hump, hirsutism and virilization were not present. Initial bio-chemical evaluation revealed hyperlipidemia, normal thyroid function and A1C. Further testing included screening for Cushing’s syndrome. 24 hour urine free cortisol was 418 ug/24 hour (58-403). After an overnight 1-mg dexamethasone suppression test, cortisol level (15.3 ug/dL) failed to suppress. Saliva cortisol levels were elevated (0.51 mcg/dL, 0.49 mcg/dL (< 0.09)). Plasma ACTH level was 54 pg/mL (5-46). In order to determine the etiology of Cushing’s syndrome, a high-dose dexamethasone suppression test (overnight 8 mg) was performed; the patient’s serum cortisol level suppressed by ~75 % (6.2 ug/dL). Pituitary magnetic resonance imaging revealed 5 mm pituitary microadenoma. At this time, patient was referred to neurosurgery. After transphenoidal resection of the pituitary adenoma, nadir cortisol was 1.2 ug/dL on post-op day 1. At her 3 and 6 month follow up, the signs and symptoms of hypercortisolism had gradually improved. Fatigue had reduced and patient reported significant improvement in her mood. Conclusion: Cushing’s is rare in children and adolescence. A high index of suspicion of Cushing’s is essential for its diagnosis in adolescents with psychological problems, behavioral changes and weight gain.