This young lady presented with irregular menstruation, weight gain, excessive hair growth, and skin pigmentation over the past 6 years. Her lab tests and symptoms are consistent with Cushing's syndrome, as she has elevated cortisol and ACTH levels. Further management may include pituitary imaging to determine the cause, and treatment options like surgery or medication to lower cortisol levels. With successful treatment to control her Cushing's syndrome, she has a good chance of leading a normal life including marriage in the future.

1. A young lady with progressive
weight gain, irregular
menstruation, hirsutism and
pigmentation
Dr. Naresh Parajuli
Phase –A resident
Endocrinology and Metabolism
BSMMU

2. 23 years
Unmarried , female
Student
Admitted through OPD on 12/5/2013

3. Presenting complains
Irregular menstruation for 6 years
Progressive weight gain for 3 years
Excessive hair growth for 2 years
Pigmentation for 2 years

4. History of present illness
Irregular menstruation 6 years back
Occurring in every 40-45 days
Menstrual bleeding lasting for 1-2 days
Blood loss scanty in amount
• She attended her menarche at 13 years of age
which used to be regular ,normal in amount of blood
loss and no eventful history for the next 4 years.

5. History of present complain contd..
Progressive weight gain for 6 years
• Weight gain during her childhood to adolescent period
was as similar to other relatives of her age.
• Not associated with excessive serving size of food or
increased snacking habit.
• Used to walk on foot to her school and college daily.
• No history of binge eating or nocturnal eating.
• Recorded weight 3 years back was 60 kg and 85 kg at
present
• Associated with mechanical back pain , knee and ankle
joint pain

6. History of present illness
Excessive undesirable hair growth over her
face,chin,chest ,back ,limbs.
Not associated with changes of voice or balding of
hair.
Associated with generalized dark pigmentation on
the pressure areas , more on the bony prominences of
palmer and dorsal surface of hands ,medial malleoli,
knee joints and neck.
Not associated with enlargement of forehead,jaw
hands and foot and visual problems.

7. History of present complain….
She has been visiting different local practitioners for
the last 6 years.
2 years back was diagnosed as a case of PCOS with
hypertension
For the last one year she was on
amlodipine+atenolol, losartan+hydrochlorothiazide,
Estrogen and spirolactone
Her symptoms didn’t subside and was referred to
BSMMU for further evaluation and management.

8. Past history
No genital abnormalities at birth
No history of dehydration ,syncope or
unconsciousness preceded by infection or stress.

9. Drug history
No history suggestive of any drugs or inhalers taken
for chronic respiratory disease or skin diseases or any
herbal medicines.

10. Family history
HTN
DM
HTN
No family history of virilisation
or pigmentation.

11. Socio-economic history
Lives in urban area
Student of management( Masters level 1st
year )
Earning member of the family-father (grocery
shopkeeper)
Support from the family

12. General Examination
Looks depressed.
Obese with truncal fat distribution and relatively lean and
thin limbs
Deposition of fat at the root of neck and supraclavicular
fossa.
Acanthosis negricans over neck and axilla
Moonlike ,puffy face ,baggy eyelid swelling with excessive
hair over chin ,back ,limbs.
Dark pigmentations pressure areas , more on the bony
prominences of palmer and dorsal surface of hands
,medial malleoli, knee joints and neck

14. s

15. General examination
Height-153cms
Weight-85 kgs
• BMI-36kg/m2
Waist circumference-123cms
No anemia, Icterus,lymphadenopathy,cyanosis ,edema
dehydration or raised JVP
Pulse-100 bmp
Bp-180/100 mmHg(on admission 200/120mm Hg)
Temperature-98.6 f
Respiratory rate-18/minute

16. Systemic examination
Per abdomen examination-
Whitish Stria seen
No organomegaly or masses on palpation.
Genitourinary examination-No cliteromegaly seen
Neurological examination
No visual defect in confrontation test
No abnormality in other systemic examinations

17. Differential diagnosis
1)Cushing syndrome due to pituitary cause(cushing’s
disease
2)Polycystic ovarian disease
3)Metabolic syndome
4)Late onset congenital aderenal hyperplasia

18. Cushing’s syndrome
Points in favour Points against
Facial presentation No purple stria
Truncal obesity,
buffalo hump
Hirsutism,hypertension
No brushing
Presentation of
pigmentation
No Myopathy

19. Polycystic ovarian syndrome
Points in favour Points against
Young obese female
Irregular menstruation
Diagosis made after exclusion
Hirsutism Onset of irregular
menstruation after
peripubertal period
Typical presentation of
pigmentation

20. Metabolic Syndrome
Points in favour Points against
Obesity
Hypertension
Typical facies
Presentation of dark
pigmentation
Family history of diabetes
mellitus,hypertension
Acanthosis Negricans

21. Investigations
Hormonal profile
Basal Cortisol-911 nmol/l (138-690 nmol/l)
Prolactin-6.16ng/ml (1.9-25 ng/ml)
Testesterone-78ng/dl (63-120 ng/ml)
FSH-1.27miu/ml (2.8-11.3 miu/ml)
LH-1.10miu/ml (1.1-11.6miu/ml)
ACTH-186mic gm/24 hr (up to 46pg/ml)
24 hour urine free cortisol test -186mic.gm/24 hr
(50-190 mic.gm/24hr)
FT4-1.30 ng/dl (0.8-1.8ng/dl)
TSH-o.52mIU (0.35-5.5mIU/ml

22. Investigations
Fasting blood glucose-4mmol/l
Serum cholesterol-212mg/dl
HDL-40 mg/dl
LDL-135mg/dl
TG-182mg/dl
S.potassium -3.9mm0l/l
S.sodium-144mmol/l
Abdominal ultrasound -fatty changes in
liver,bilateral small ovaries with multiple immature
follicles

23. Problems
What is the diagnosis of the case?
What should be the further plan for the management
of the case?
What is the chance for the patient to lead a normal
married life?

24. Thank you