Woman’s Cushing’s diagnosis missed before weight-loss surgery: Report
'Classic features' of the syndrome recognized after unsuccessful bariatric surgery
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Early screening for underlying causes of obesity before weight-loss surgery, including Cushing’s syndrome in individuals with suggestive signs, may help improve outcomes and reduce unnecessary procedures.
That’s according to a report that described the case of a woman in Saudi Arabia who underwent unsuccessful bariatric surgery and was ultimately diagnosed with Cushing’s syndrome caused by tumors in the adrenal glands.
“Timely diagnosis and appropriate management are essential, as they can significantly improve outcomes, prevent unnecessary interventions, and reduce the risk of long-term complications,” the researchers wrote.
The report, “Cushing Syndrome Secondary to Adrenal Adenoma Diagnosed Following Unsuccessful Bariatric Surgery: A Case Report,” was published in Case Reports in Endocrinology.
Cushing’s diagnosis missed at first presentation
Cushing’s syndrome refers to conditions caused by excessive production of the hormone cortisol. In many cases, it is caused by tumors in the pituitary gland that produce excess adrenocorticotropic hormone (ACTH). This specific type of the syndrome is known as Cushing’s disease. ACTH triggers the adrenal glands, located above the kidneys, to produce cortisol.
The syndrome may also arise from ACTH-secreting tumors located outside the pituitary gland — referred to as ectopic Cushing’s syndrome — or from adrenal tumors that directly produce excess cortisol (ACTH-independent).
A diagnosis of Cushing’s after bariatric surgery has emerged as a clinical concern, leading to complications like inadequate weight loss and mortality.
Here, a duo of researchers in Saudi Arabia described the case of a 26-year-old woman diagnosed with Cushing’s syndrome caused by an adrenal tumor following bariatric surgery, a weight-loss procedure.
The woman had progressively gained weight since she was 20, and developed high blood pressure, or hypertension, and diabetes at age 22. Despite undergoing a sleeve gastrectomy — a bariatric surgery to remove most of the stomach — and adhering to a healthy diet and exercise, she only lost 15 kg (about 33 lbs) over one year, with continued hypertension and diabetes.
According to the researchers, in retrospect, she had classic signs of Cushing’s before the surgery, “but this diagnosis was missed at her first presentation.”
Woman had classic signs of excessive cortisol production
A physical examination revealed a rounded face with acne, thick facial hair, thin hair on the head, fat buildup between the shoulder blades and around the abdomen, wide purple abdominal stretch marks, and easy bruising. She also reported that her menstrual period had been absent for one year.
Laboratory work indicated excess cortisol, or hypercortisolism, as well as low-normal levels of female reproductive hormones and elevated levels of testosterone (a male sex hormone). Also, the low-dose dexamethasone suppression test, used to assess excessive cortisol production, failed to suppress cortisol levels despite reducing ACTH levels, suggesting ACTH-independent Cushing’s.
Imaging tests revealed the presence of tumors in both adrenal glands, with the largest nodule present in the right adrenal gland. She also presented with low bone density — a condition in which bones have low mineral content, decreasing bone strength.
This case highlights the need to consider [Cushing’s] both before bariatric surgery, particularly in patients with multiple features of hypercortisolism, and in patients with poor outcomes post bariatric surgery.
The woman underwent surgery to remove the right adrenal gland through a minimally invasive procedure. After surgery, her cortisol levels were below normal levels, indicating adrenal insufficiency, and she initiated hydrocortisone replacement therapy.
Four months after surgery, the woman had experienced an additional weight loss of 10.5 kg (about 23.15 lbs), normalization of blood pressure, and a significant decrease in blood sugar levels. Her menstrual cycle became regular after one year, and she was able to discontinue all antihypertensive and antidiabetic medication. After an additional year, she also stopped hydrocortisone replacement therapy.
“This case highlights the need to consider [Cushing’s] both before bariatric surgery, particularly in patients with multiple features of hypercortisolism, and in patients with poor outcomes post bariatric surgery,” the researchers wrote.
“Though rare, it is a reversible and treatable cause of obesity that should not be missed when clinical features are suggestive,” they added.
