Cushing’s disease behind woman’s unexplained blood clots: Case study
Diagnosis comes years after 2 episodes of deep vein thrombosis
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A history of unexplained deep vein thrombosis, or blood clots in the deep veins, in an obese woman was ultimately revealed as an undiagnosed case of Cushing’s disease, according to a case study.
Venous thromboembolism, a group of conditions that includes deep vein thrombosis and pulmonary embolism (when blood clots travel to the lungs), is a known complication of Cushing’s disease.
In this case, the blood-clotting events were unprovoked, meaning there was no obvious trigger such as surgery, trauma, or immobilization.
“We conclude that Cushing’s disease should be viewed as a risk factor for unprovoked venous thromboembolism and screened for, especially in obese patients,” researchers wrote.
Case details were described in the study, “Unprovoked Deep Vein Thrombosis as a Manifestation of Cushing’s Disease,” published in Cureus.
Woman’s complex medical history included colon cancer, fibromyalgia
In Cushing’s disease, tumors in the brain’s pituitary gland release high levels of adrenocorticotropic hormone (ACTH). This triggers the adrenal glands, which sit atop the kidneys, to overproduce cortisol, leading to a wide range of symptoms.
Elevated cortisol is also linked to an increased risk of venous thromboembolism.
In this case, a woman had earlier experienced two episodes of unprovoked deep vein thrombosis, with no risk factors identified at the time, but was eventually diagnosed with Cushing’s disease years later.
She sought medical evaluation for thyroid nodules (fluid-filled lumps on the thyroid gland) and a range of other symptoms, including weakness in her thighs and other muscles, body aches, easy bruising, and difficulty sleeping.
Her medical history was complex and included multinodular goiter (enlarged thyroid gland), colon cancer, fibromyalgia, obesity treated with a gastric sleeve, high blood pressure, and sleep apnea. She had also undergone spine surgery for chronic pain and had received cortisone injections in the past, but not within the last year.
The woman had experienced two episodes of deep vein thrombosis, which she said were unprovoked. Because of this risk, doctors had placed an inferior vena cava filter, a device designed to prevent clots from traveling to the lungs.
MRI reveals tumor in pituitary gland
During the current physical exam, the woman was classified as obese with a noticeable “buffalo hump,” a fat deposit at the back of the neck sometimes seen in Cushing’s. Yet, she didn’t have other classic Cushing’s signs such as a round “moon” face or purple stretch marks. Her muscle strength was normal, and her heart and lung exams were also normal.
After blood, urine, and saliva tests showed elevated ACTH and cortisol levels, doctors ordered a brain MRI scan, which revealed a tumor in the pituitary gland. The growth, called a macroadenoma, was located on the left side of the gland, but had not spread into nearby tissues. Further hormone testing supported the diagnosis of Cushing’s disease.
The woman successfully underwent a common surgical procedure to remove the pituitary tumor. In lab analysis, multiple tests confirmed the tumor was a relatively slow-growing ACTH-producing pituitary macroadenoma.
After surgery, her cortisol level remained low, so she was prescribed hydrocortisone to replace the cortisol her body was not yet producing on its own. Soon after, she experienced cortisone withdrawal symptoms, including body aches, but she also lost nearly 60 pounds during her recovery. About two years after surgery, her hormonal system had not fully returned to normal, so she remained on daily hydrocortisone.
“Cushing’s disease is a risk factor for venous thromboembolism,” the researchers concluded. “We need larger prospective studies to look into the duration, timing, and preferred anticoagulation in these patients perioperatively, and also to add [Cushing’s] as a risk factor in [venous thromboembolism] guidelines.”
