Obesity screening in Cushing’s may aid bariatric surgery outcomes
A 42-year-old man in Iraq developed complications after weight-loss procedure
Early screening and treatment for possible underlying causes of obesity, such as Cushing’s disease, before a weight-loss procedure called bariatric surgery may help prevent mismanaging the condition and improve patient outcomes.
That’s according to a report that described the case of a man in Iraq who developed complications and died following bariatric surgery with undiagnosed Cushing’s disease.
“Screening for [Cushing’s disease] before bariatric surgery may prevent mismanagement and complications,” the researchers wrote. The case report, “Challenges of Cushing’s syndrome and bariatric surgery: a case report with literature review,” was published in Journal of Surgical Case Reports.
Cushing’s is caused by a tumor in the pituitary gland that leads to the excessive production of adrenocorticotropic hormone (ACTH), which stimulates the adrenal glands atop the kidneys to produce and release too much cortisol, a hormone that helps regulate metabolism, blood sugar, blood pressure, and the body’s response to stress.
When cortisol remains high for too long, a wide range of symptoms may arise, including weight gain, high blood pressure, muscle weakness, and unusual fat distribution. These symptoms often develop gradually and can easily be confused with more common conditions, especially obesity.
“Diagnosing [Cushing’s syndrome] in bariatric patients is challenging due to symptom overlap with obesity-related conditions,” the researchers wrote. “No single test distinguishes [Cushing’s syndrome] from primary obesity.”
Undiagnosed Cushing’s disease
The man, 42, had severe obesity and high blood pressure, and underwent bariatric surgery to improve his health. At the time, no one suspected Cushing’s disease.
About a month after surgery, he returned to the hospital with severe fatigue and increased weakness, to the point that he could no longer walk or move around without help. He also reported joint pain.
His doctors noticed several characteristic signs of Cushing’s disease during a physical exam. These included large stretch marks, called striae, on his abdomen, dark pigmented skin patches, especially over his knuckles, and easy bruising. He also had central obesity.
Blood tests showed extremely high cortisol levels and abnormally elevated ACTH. A dexamethasone test, commonly used to diagnose Cushing’s disease, showed his body didn’t reduce cortisol production in response to a low dose of dexamethasone, consistent with Cushing’s disease. An MRI of his brain revealed a large tumor in his pituitary gland, confirming a diagnosis.
The man was admitted to the intensive care unit and underwent transsphenoidal surgery, a minimally invasive procedure to remove the pituitary tumor through the nose. His cortisol and ACTH levels remained elevated, however.
He was soon readmitted to the hospital due to worsening lower limb weakness, myopathy (muscle disease), and low blood pressure. A follow-up MRI scan revealed a residual tumor. A second surgery or radiation treatment was considered, but both options were deemed too risky.
He was started on ketoconazole, which blocks cortisol production. Although his symptoms initially eased, he developed liver failure and soon died.
According to the researchers, about 65% of people with Cushing’s disease who had bariatric surgery were misdiagnosed. Most had signs and symptoms that could have raised suspicion.
“Bariatric surgery has risen globally, improving obesity-related conditions. However, undiagnosed [Cushing’s syndrome] in [bariatric surgery] patients may worsen outcomes,” the researchers wrote. “Early screening and treatment before [bariatric surgery] improve outcomes.”
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