Case Report: Differentiating Obesity from Subclinical Cushing's Syndrome

Introduction: There is sustained trend of increased prevalence of obesity all over the world. The main cause is lifestyle, although small percentages of obese patients have additional cause of obesity, e.g. hypercortisolism. Some subtypes of hypercortisolism are more subtle, like subclinical Cushing's syndrome. Such patients have adrenal adenoma with autonomous cortisol secretion, not completely controlled by pituitary. They do not have typical physical features of hypercortisolism. It is impossible to screen all adult obese population for hypercortisolism or to refer them to a specialist Subclinical Cushing has many common characteristics with obesity and it is not easy to discover, might be frequently missed in large mass of "just obese" patients. Case: 50 years old female patient presented with enormous weight gain of 60 kg in 8 years, unacceptable diabetes control despite insulin/metformin therapy, unregulated hypertension and hyperlipidemia. Lack of suppression in 1-mg overnight dexamethasone test, low morning ACTH and suppressed DHEA-rose suspicion about ACTH independent hypercortisolism. MSCT showed homogeneous low density mass of right adrenal gland measuring 4.9x3.6 cm. Laparoscopic adrenalectomy was performed, PHD confirmed adenoma. Four months after surgery her blood pressure was normal with the same therapy, she lost 17 kg, her lipid panel and diabetes control were significantly better. UKPDS calculated cardiovascular risk for heart disease was 33% and for fatal coronary heart disease 43% lower after surgery. Conclusion: Patients with subclinical Cushing syndrome are hard to distinguish from other obese people. They have metabolic benefits form surgery followed with lower long term cardiovascular risk reduction. Obese people with diabetes and hypertension that appear suddenly and/or are hard to control might be candidates for screening with 1 mg overnight dexamethasone test, though the best way to differentiate patients with Cushing's syndrome from those with obesity is combined dexamethasone-suppressed corticotropin-releasing hormone.