This document presents the case of a 36-year-old Saudi female who presented with lower back pain, headaches, and inability to walk for 3 months. She had a history of hypertension, diabetes, and dyslipidemia. Examination revealed signs of Cushing's syndrome including obesity, hirsutism, and bruising. Laboratory results found hypokalemia and elevated cortisol levels. Brain imaging detected a cystic mass compressing the pituitary gland. She was diagnosed with Cushing's disease caused by an ACTH-secreting pituitary adenoma, which was the underlying cause of her hypercortisolism and associated symptoms.

1. Case presentation
Done by: Dr. Rahma ShahBahai
Medical intern

2. History…
 36 y.o single Saudi female k/c of HTN, T2DM and dyslipidemia
 Direct admission from OPD.
 Presented with lower back pain, headache and inability to walk
for 3 months.
 referred from KFH (Hafof) for persistent hypokalemia for further
investigation.

3. HPI:
 3 months Hx of progressive bilateral lower limbs weakness.
 Start as a simple weakness>>can’t carry her weight during
standing>>become wheelchair bound.
 Headache and lower back pain.
 No Hx of sphincter incontinence.

4. Drug Hx:
 Aldactone 50 mg PO BID
 Nifedipine 40 mg PO OD
 Hydralazine 50 mg PO Q6H
 Atorvastatin 20 mg PO OD
 Labetalol 100 mg PO BID
 Diamicron 90 mg PO OD

5. PH:
 uncontrolled HTN >10 years
 Dyslipidemia+T2DM ~3month
 2ry Amenorrhea ~15 yrs.
His menarche @ 13>> stopped
didn't seek medical advice.
 No surgical Hx.

6. FH:
 father in good health.
 Mother >>HTN
 Sis1: HTN+DM
 Sis 2: passed away (leukemia)
 sis 3: weight gain+2ry amenorrhea

7. Systemic review:
 No mood changes
 No dizziness
 No blurred vision
 excessive hair growth
 acne
 No respiratory or cardiac symptoms
 No nausea, vomiting, diarrhea or constipation
 No urinary symptoms

8. D.Dx ???

9. Examination…
 General:
 Obese, round face, comfortable in the bed, not in distress.
 Vitals: T 37.7 ,p 90, RR 18, BP 160/100
 Skin:
 hirsutism, facial plethora, acne, dorsocervical fat deposition, supraclavicular fat
deposition.
 Chest: clear, good air entry bilateral.
 CVS: S1,S2+0
 Abdomen: distended, White striae ~0.5-0.7 cm, positive bowel sound.
 CNS: conscious, alert
 Extremities: bruises
 U.L: power 4/5, reflexes normal
 L.L: muscles wasting, bruises, no edema, power 3/5, reflexes normal

10. Labs:
 Cbc
 Liver panel
 Renal/lyte
 Lipid profile
All within her base line, except for:
 HB 12.7
 K 2.5

11. Hospital course…
 Pt. loss of her consciousness < 1min.
 Notice abnormal movement, not typical for convulsion
 K 2.4
 ICU transferred.
 Observation, K-replacement, ECG

13. Investigations???

14. Labs:
 Cortisol level am 313.6
 Cortisol level pm 2017.8
 ACTH 31
 DST 331
 FT4 13.5
 FT3 2.44
 T3H 0.09(SET)
 E2 142
 LH <0.07
 FSH 0.09

15. Brain CT:
cystic density 20*20 nm seen compressing
the pituitary gland

17. Brain MRI:
cystic mass lesion 2.5*1.7 cm with evidence of
hemorrhagic is seen, optic chiasma is displaced
cronaly
Finding consistent rathke cleft cyst complicated
by hemorrhagic or cystic degeneration of
pituitary macro-adenoma.

18. Diagnosis is…..?
ACTH-dependent Cushing’s syndrome

20. Harvey Williams Cushing

21. Cushing’s Syndrome= Hypercortisolism
Cushing's disease= Cushing's syndrome 2ry to pituitary ACTH
hypersecretion

22. Etiologies:
 Iatrogenic= exogenous glucocorticoid>>most
common
 Cushing’s disease= endogenous 70%
 Pituitary adenoma/hyperplasia
 Adrenal tumor 25%
 Ectopic ACTH 10%:
 Carcinoid, SCLC, medullary thyroid cancer, pheo.

23. Approach…

24. TTT..
 Mainly>>surgical resection
 Medication
 Replacement therapy lifelong.

25. Thank you….