Rare Cushing’s Syndrome Case From Pituitary, Adrenal Tumors: Report

Patricia Inácio, PhD avatar

by Patricia Inácio, PhD |

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A technician readies a patient to have an MRI scan.

A 37-year-old woman developed Cushing’s syndrome due to the rare simultaneous presence of tumors in the pituitary and adrenal glands, according to a recent case report.

In these cases, “an accurate clinical, physical and endocrine examination is always recommended,” the researchers wrote.

The case report, “Simultaneous pituitary and adrenal adenomas in a patient with non ACTH dependent Cushing syndrome; a case report with literature review,” was published in the International Journal of Surgery Case Reports.

Cushing’s syndrome is triggered by high levels of glucocorticoids, such as cortisol. A pituitary adenoma — a tumor in the brain’s pituitary gland — that produces and releases high levels of adrenocorticotropic hormone (ACTH), increasing cortisol levels, is responsible for 60–70% of cases, a condition known as Cushing’s disease.

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In 20–30% of the cases, however, the condition develops independently of ACTH, usually due to a tumor in the adrenal glands — those sitting atop the kidneys that are responsible for cortisol production.

Researchers in Iraq described the case of a 37-year-old woman with Cushing’s syndrome due to simultaneous pituitary and adrenal adenomas.

The patient went to the hospital after missing her menstrual cycles for one year (a condition called amenorrhea), which was accompanied by weight gain. She had no medical history of chronic disease and steroid use.

She was treated with thyroxin for her hypothyroidism, a condition wherein the thyroid gland in the neck fails to produce enough of certain hormones, and received oral contraceptive pills for her menstrual problems.

She was referred to an endocrinology clinic and a physical exam revealed she had excessive amounts of fat around the waist (central obesity) and behind the neck (“buffalo hump”), swelling in the face (“moon face”), and pink streaks across the abdomen (stretch marks), all typical symptoms of Cushing’s syndrome. She also showed weakness in her arms.

Suspecting Cushing’s syndrome, clinicians ordered an MRI scan that revealed a small tumor in her pituitary gland called micro-adenoma.

Tests conducted six weeks after she was instructed to halt her medications to not influence the results revealed excessively high levels of cortisol in her urine. This test, called 24-hour urinary free cortisol, was conducted three times. Each time the levels were elevated.

Her blood cortisol levels did not drop after an overnight dexamethasone suppression test (ODST), which measures cortisol levels in the morning after patients take a tablet of dexamethasone, a corticosteroid that normally blocks its production.

Her ACTH levels were low, however, suggesting she likely had an ACTH-independent form of Cushing’s. A CT scan revealed an adenoma in her left adrenal gland with no signs of malignancy.

The patient underwent a laparoscopic adrenalectomy, surgery to remove one of both adrenal glands through tiny holes in the abdomen. She was released after two days with instructions to take oral hydrocortisone twice-daily, a common prescription for people with adrenal insufficiency, which occurs when the adrenal glands fail to produce sufficient amounts of certain hormones.

After one month of follow-up, her cortisol levels dropped, she lost weight, and her pink stretch marks had became white.

“The coexistence of adrenal adenoma and pituitary adenoma with [Cushing’s syndrome] is a rare possibility,” the researchers wrote. “Laparoscopic adrenalectomy is the gold standard for treating adrenal adenoma.”