Psychosis From Cushing’s Treated With Surgery Plus Metopirone
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A young woman with psychosis stemming from Cushing’s disease made a complete recovery through a combination of brain surgery and Metopirone (metyrapone) treatment, according to a case report.
The researchers noted that Cushing’s disease is challenging to diagnose and often occurs alongside neuropsychiatric symptoms. Catching and treating it early, however, can result in good patient outcomes, the team said.
“Neuropsychiatric symptoms are well recognised and over 70% of patients with active Cushing’s syndrome show these,” the researchers wrote, adding that “an early specialist endocrinological opinion is highly recommended” in suspected cases so as to speed diagnosis and treatment.
This woman’s case was described in a study, “Cushing’s disease presenting with psychosis,” published in the journal Practical Neurology.
The 24-year-old patient was treated at a U.K. hospital after three weeks of intermittent headaches, short-term memory problems, paranoid thoughts, and confabulation — a condition in which a person fills in memory gaps with made-up stories. Notably, however, the woman had no previous history of mental illness.
The healthcare providers noted that the woman was found to also have polycystic ovary syndrome, a hormonal disorder in which numerous cysts form on the outer edges of the ovaries.
A full neurological exam appeared normal, although the patient discharged herself before undergoing a planned MRI brain scan.
Her condition worsened over the following seven weeks, resulting in her twice being placed in custody under the Mental Health Act. This U.K. law enables people to be detained and treated without consent in certain cases involving psychiatric symptoms. It is often referred to as being “sectioned.”
Over the course of these two admissions, the woman’s mental state declined markedly, developing into “florid psychosis,” an acute schizophrenic state involving severe delusions and/or hallucinations, disorganized thinking and speech, and abnormal emotional expression, among other symptoms. Interestingly, it was noted that her mental state worsened cyclically, growing especially pronounced for a few hours at night.
During her hospital stays, doctors noticed excess hair growth on her chin, shoulders, and back, along with worsening acne, and low potassium levels despite supplements. An MRI scan then showed signs of cerebral atrophy, a condition in which certain regions of the brain waste, diminishing in size.
Further examination also revealed fat accumulation in the face — sometimes referred to as “moon face,” a Cushing’s symptom — and stretch marks on her abdomen.
This combination of physical, biochemical, and psychiatric symptoms led doctors to suspect hypercortisolism, or excessively high levels of the hormone cortisol in the body, the defining characteristic of Cushing’s disease.
Since Cushing’s generally stems from a tumor in the brain’s pituitary gland, physicians ordered an MRI scan. That scan showed the patient had an 8 mm tumor, called a pituitary microadenoma.
The medical team then diagnosed the woman with Cushing’s disease, and started her on Metopirone to suppress cortisol production and stabilize her mood. Surgery then was done to remove the tumor.
The woman gradually improved over the following two months, and eventually made a complete recovery, the team reported.
The researchers noted that Cushing’s disease is a challenge to accurately diagnose, as it is rare, its symptoms often do not occur together, and many overlap with those of other disorders. In this case, for instance, the woman’s excessive hair growth, acne, and abnormal fat accumulation are indicative of both Cushing’s and polycystic ovary syndrome, with which the patient also was diagnosed.
“Cushing’s disease should be considered in people with psychosis and delirium,” the team wrote, adding that “non-specific clues in the appropriate clinical context, such as unexplained hypokalaemia [low blood potassium levels] and cerebral atrophy out of keeping with age, can suggest Cushing’s disease.”
Making an appropriate diagnosis is imperative to getting the patient proper treatment, they noted.
“Diagnosing Cushing’s disease can be challenging, but with early diagnosis and treatment it has an excellent prognosis,” the team concluded.
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