Rare case report reveals Cushing’s can lead to neurological symptoms

1st reported case of Cushing’s with functional neurological disorder

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by Andrea Lobo |

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A recent case of a man with Cushing’s disease illustrates a rare psychiatric manifestation of the disease — symptoms of functional neurological disorder (FND), according to a report.

FND is where patients experience a series of neurological symptoms in the absence of a neurological disorder.

“To our knowledge, this is the first reported case of a patient with [Cushing’s syndrome] presenting with FND…. Successful treatment of Cushing’s syndrome with FND requires a multidisciplinary approach,” researchers wrote.

The report, “Cushing’s Disease Presenting with Functional Neurological (Conversion) Disorder,” was published in the journal Case Reports in Psychiatry.

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Cushing’s syndrome is characterized by excessive levels of the stress hormone cortisol, which is produced by the adrenal glands located atop the kidneys.

The most common form of the syndrome, Cushing’s disease, is caused by a tumor in the brain’s pituitary gland, which releases excessive amounts of adrenocorticotropic hormone (ACTH) — a hormone that signals the adrenal glands to produce cortisol.

Cushing’s syndrome is frequently associated with neuropsychological and cognitive changes. In some cases, psychiatric illness may be the presenting symptom, the most common being depression, irritability, and anxiety.

Man, 28, had Cushing’s and multiple functional symptoms

In this report, researchers described the case of a 28-year-old man with Cushing’s disease and multiple functional symptoms, including psychiatric symptoms and FND. Also known as conversion disorder, FND is characterized by neurological symptoms — such as motor dysfunctions, sensory symptoms, speech disorders, and nonepileptic seizures — that occur in the absence of a neurological disease.

The patient, whose medical history included paraplegia of unknown origin for six months, which caused him to become bedbound, a seizure disorder, and high blood pressure, was admitted to the hospital because he was experiencing more frequent seizures.

At the initial presentation, he had high blood pressure and accelerated heartbeat and breathing, but normal oxygen levels. A physical examination revealed he had decreased strength in his arms and hands, and was unable to lift his legs. He was also unable to communicate verbally. Laboratory analysis indicated he had low blood levels of potassium and platelets.

After taking lorazepam for anxiety, he regained the ability to follow simple commands and communicate. The patient underwent electroencephalogram monitoring to assess brain activity for three days, during which he experienced multiple episodes of body, limb, and head shaking without epileptiform discharge (or disruption of the usual functioning of the brain), which indicated that his seizures were being caused by psychological issues.

A psychiatric evaluation identified symptoms of depression and psychosis, including depressive mood, disinterest in social contact, psychomotor retardation, suicidal ideation, and auditory and visual hallucinations, for which he was started on antipsychotic medication. He experienced less frequent seizure-like episodes when on the medication.

At this point, the researchers learned of a previous diagnosis of Cushing’s disease associated with weight gain and striae (stretch marks), for which the patient was not treated due to his psychiatric symptoms. This diagnosis was confirmed after laboratory tests showed the patient had high cortisol levels in the blood and urine, as well as high blood ACTH levels.

An MRI scan revealed a pituitary tumor in the patient, who was then treated with cabergoline and ketoconazole, leading to a reduction of blood cortisol to near-normal levels. Surgery to remove the tumor is planned as a definitive treatment.

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Multidisciplinary approach to treatment helped relieve patient’s symptoms

Treatments to alleviate the patient’s psychiatric and Cushing’s symptoms, together with psychology, physical, and occupational therapy, allowed him to regain control of his hand and start eating independently and writing. He was once again able to stand up and walk with assistance. His psychiatric symptoms also eased.

“With this [multidisciplinary] approach, there was improvement in [seizure] frequency, upper and lower extremity strength, hand function, and speech over the course of the hospital stay,” the researchers wrote.

The patient’s FND and other psychiatric symptoms are expected to ease further after he undergoes surgery to remove the pituitary tumor.

However, “studies have shown that neuropsychiatric symptoms may persist for at least one year in some patients despite medical or surgical treatment of [Cushing’s syndrome] leading to normalization of cortisol levels,” the researchers wrote.