Global Longitudinal Strain Reduction With Apical Sparing in Cushing Syndrome-Related Heart Failure With Preserved Ejection Fraction (HFpEF): A Case Report

Posted on December 5, 2025 by MaryO

Abstract

We describe a case of a 56-year-old woman with a history of recurrent pituitary adenoma, not well followed, and known comorbidities of coronary artery disease, hypertension, and type 2 diabetes mellitus. She arrived with severely high blood pressure and signs pointing to hypercortisolism. Further evaluation revealed left ventricular hypertrophy, reduced global longitudinal strain, and preserved left ventricular ejection fraction, consistent with heart failure with preserved ejection fraction (HFpEF). Workup for amyloidosis was negative. This case highlights that chronic hypercortisolism may cause pathophysiological changes in the heart, leading to HFpEF, and may induce myocardial fibrosis and impaired myocardial mechanics, producing an echocardiographic pattern that can mimic infiltrative cardiomyopathy. Recognition of this overlap is crucial to avoid misdiagnosis and to ensure timely endocrine and cardiovascular management.

Introduction

Hypercortisolism is defined as a clinical condition resulting from excessive tissue exposure to cortisol or other glucocorticoids. Sustained exposure ultimately leads to Cushing syndrome (CS), a well-established constellation of clinical manifestations arising from chronic endogenous or exogenous cortisol excess [1]. CS is associated with profound metabolic derangements that significantly increase cardiovascular risk, not only during the active phase of the disease but also persisting long after biochemical remission [2,3]. Cardiovascular complications, including premature atherosclerosis, coronary artery disease (CAD), heart failure, and cerebrovascular events, are major contributors to the excess mortality observed in CS compared with the general population [1,3]. Among these complications, arterial hypertension remains the most frequent cardiovascular disorder in patients with Cushing disease (CD) [4].

Although left ventricular (LV) systolic function is generally preserved in patients with CS, several studies have demonstrated that chronic cortisol excess induces structural and functional cardiac alterations, predisposing to major adverse cardiac events and the development of heart failure [5] In the broader context of chronic congestive heart failure, disease progression is tightly coupled with activation of neuroendocrine stress pathways, most notably the hypothalamic-pituitary-adrenal axis, which governs cortisol secretion [6]. Cortisol, a pivotal stress hormone, increases in response to physiological strain, and its sustained elevation contributes to adverse myocardial remodeling.

Heart failure with preserved ejection fraction (HFpEF), a chronic and progressive syndrome, exemplifies the deleterious effects of persistent myocardial stress. While overt heart failure is an uncommon complication of CS, when it does occur, it most often presents with preserved LV ejection fraction (LVEF) or with subclinical LV dysfunction [7]. Prior evidence has also linked CS to LV hypertrophy, diastolic dysfunction, and subtle systolic impairment, with many of these changes demonstrating reversibility upon normalization of cortisol levels [8].

This case is unique as it highlights the interplay between CS and cardiac amyloidosis, emphasizing their overlapping yet distinct echocardiographic features. Global longitudinal strain (GLS), a measure of myocardial deformation, is particularly useful for differentiating these conditions and reveals subtle differences in strain patterns between the two.

Case Presentation

A 56-year-old woman with a significant past medical history of recurrent pituitary macroadenoma, treated with two prior surgical resections, the most recent five years earlier without subsequent follow-up, CAD, long-standing hypertension, and type 2 diabetes mellitus, presented to the emergency department with hypertensive urgency.

On arrival, she presented with a hypertensive crisis, with blood pressure measured at 200/110 mmHg, associated with severe cephalalgia, without syncope, visual changes, or focal neurological deficits. An MRI Brain demonstrated no evidence of acute intracranial hemorrhage or mass effect (Video 1). Initial laboratory testing showed normal complete blood count, renal function, and serum electrolytes. On physical examination, she exhibited characteristic Cushingoid stigmata, including rounded moon facies, central adiposity, and bilateral lower-extremity pitting edema.

She was commenced on intensive antihypertensive therapy, including spironolactone, clonidine, telmisartan, carvedilol, amlodipine, and intravenous furosemide (20 mg, subsequently escalated to 40 mg). Given her clinical appearance and history of pituitary disease, an endocrine evaluation was undertaken. An overnight dexamethasone suppression test revealed an unsuppressed morning cortisol of 360 nmol/L, consistent with hypercortisolism.

Cardiac assessment supported a diagnosis of HFpEF. Transthoracic echocardiography demonstrated preserved left ventricular ejection fraction (60%), impaired GLS (-10%), and mild concentric left ventricular hypertrophy (Figure 1; Video 2).

Transthoracic-echocardiography-demonstrating-reduced-global-longitudinal-strain-(-10%)-consistent-with-preserved-EF-(60%)
Figure 1: Transthoracic echocardiography demonstrating reduced global longitudinal strain (-10%) consistent with preserved EF (60%)

EF: Ejection Fraction

Workup for alternative causes of HFpEF, including renal impairment and infiltrative cardiomyopathy, was unremarkable; both serum and urine protein electrophoresis with immunofixation excluded amyloidosis.

Magnetic resonance imaging of the pituitary revealed recurrence of the macroadenoma. The patient was referred to neurosurgery for consideration of repeat resection, and glucocorticoid-sparing medical therapy was initiated. During hospitalization, her blood pressure was gradually stabilized, diuretic therapy improved signs of congestion, and her functional status returned to near baseline with restored mobility (Video 3).

Discussion

Epidemiology and clinical significance

CD is a severe endocrine disorder characterized by chronic exposure to excess glucocorticoids. Patients with CD have a two- to fivefold higher mortality compared with the general population, predominantly due to cardiovascular complications [4]. Chronic hypercortisolism is associated with systemic hypertension, left ventricular hypertrophy (LVH), diastolic dysfunction, and accelerated atherosclerosis, increasing the risk of myocardial ischemia and heart failure. While these cardiovascular manifestations are common, the development of isolated dilated cardiomyopathy (DCM) in the absence of other major comorbidities is rare but clinically noteworthy [9].

Pathophysiology of cardiac involvement

Chronic glucocorticoid excess contributes to cardiovascular remodeling via multiple mechanisms. Persistent hypertension and metabolic disturbances promote LVH and diastolic dysfunction. Additionally, glucocorticoid excess induces endothelial dysfunction, insulin resistance, and myocardial fibrosis, impairing ventricular compliance and predisposing to HFpEF [1,6]. Advanced echocardiographic techniques, such as GLS, can detect subclinical systolic dysfunction before overt reductions in LVEF [6]. In our patient, preserved LVEF (60%) coupled with markedly reduced GLS (-10%) and concentric LVH was consistent with HFpEF secondary to chronic cortisol excess, further supported by clinical signs of volume overload such as edema and severe hypertension [7].

Apical sparing and mimicking amyloidosis

An important observation in this case was relative apical sparing despite markedly reduced GLS, a strain pattern classically associated with cardiac amyloidosis [10]. Although infiltrative disease was excluded (negative serum and urine protein electrophoresis with immunofixation), this overlap illustrates how hypercortisolism-induced remodeling can phenocopy amyloidosis on imaging. Recent work has shown that hypercortisolism, beyond metabolic derangements, impairs myocardial mechanics and contractile efficiency [11]. Thus, patients with atypical strain findings should undergo careful endocrine evaluation to avoid misdiagnosis. Ultimately, the recognition that hypercortisolism may produce amyloid-like echocardiographic signatures has both diagnostic and management implications. It broadens the differential diagnosis of HFpEF and stresses the need for a multidisciplinary approach involving endocrinology and cardiology to prevent misdiagnosis and ensure tailored therapy.

Dilated cardiomyopathy in CS

Although uncommon, DCM with severe LV systolic dysfunction has been described in CS. Frustaci et al. reported eight cases of hypercortisolism due to adrenal adenoma among 473 patients with DCM (1.7%), all presenting with LVEF <30% and symptomatic heart failure. Endomyocardial biopsy revealed cardiomyocyte hypertrophy, interstitial fibrosis, and myofibrillolysis, distinct from idiopathic DCM and valvular disease controls. Follow-up biopsies in three patients one year post-adrenalectomy demonstrated substantial regression of these changes, highlighting the reversibility of glucocorticoid-induced myocardial injury [12].

Although not assessed in our patient, prior studies have implicated atrogin-1 in CS-related myocardial remodeling. At the molecular level, upregulation of atrogin-1, an E3 ubiquitin ligase expressed in skeletal, smooth, and cardiac muscle, was observed in CS-associated DCM compared with idiopathic DCM and controls [13]. Atrogin-1, implicated in skeletal muscle atrophy and sarcopenia, facilitates proteasomal degradation of intracellular proteins. Its overexpression in cardiomyocytes contributes to glucocorticoid-mediated myocardial remodeling. Importantly, atrogin-1 expression declined significantly following surgical correction of cortisol excess, paralleling improvements in cardiac structure and function. This reversibility mirrors recovery seen in glucocorticoid-induced skeletal myopathy and underscores the unique potential for cardiac recovery in CS-related DCM [9].

Clinical implications and differential diagnosis

This case underscores the multisystem burden of endogenous hypercortisolism, with particular cardiovascular susceptibility [1,6]. Chronic cortisol excess should be considered in the differential diagnosis of HFpEF, particularly when conventional risk factors coexist with systemic features such as central obesity, moon facies, and proximal myopathy [8]. Secondary causes of HFpEF, including cardiac amyloidosis, were excluded, supporting hypercortisolism as the primary etiology. Recognizing CS as a reversible contributor to myocardial dysfunction has important clinical implications, as timely endocrine intervention can improve cardiac function, lower blood pressure, and potentially prevent progression to irreversible myocardial remodeling.

Left ventricular hypertrophy and structural remodeling

Electrocardiographic and echocardiographic studies have characterized the cardiac phenotype in patients with CS. In a cohort of 12 consecutive patients, most had concomitant hypertension (11/12) and diabetes mellitus (7/12). Preoperative ECGs commonly demonstrated high-voltage QRS complexes (10 patients) and T-wave inversions (7 patients), indicative of LV strain. Echocardiography revealed LVH in nine patients, all exhibiting asymmetric septal hypertrophy. Interventricular septal thickness ranged from 16 to 32 mm, with septal-to-posterior wall ratios from 1.33 to 2.67. Compared with essential hypertension or primary aldosteronism, CS patients exhibited more pronounced LVH and a higher prevalence of asymmetric septal hypertrophy, suggesting a unique glucocorticoid-mediated remodeling pattern [13].

Postoperative follow-up in nine patients demonstrated normalization of ECG abnormalities, decreased septal thickness, and resolution of asymmetric septal hypertrophy in all but one patient, highlighting the partial reversibility of LVH following correction of hypercortisolism. The pronounced septal thickening relative to the posterior wall implies that excessive cortisol exposure, beyond hemodynamic effects of hypertension, contributes significantly to myocardial remodeling [13].

Impact of disease duration on concentric remodeling

Fallo et al. evaluated 18 patients with CS compared with 18 matched controls, adjusting for sex, age, body size, blood pressure, and duration of hypertension. Eleven participants in each group were hypertensive. Echocardiography revealed elevated relative wall thickness (RWT >0.45) in 11 patients with CS (five normotensive, six hypertensive) versus two hypertensive controls. Left ventricular mass index was abnormal in three CS patients and in four hypertensive controls, while systolic function was preserved in all participants [14].

No correlation was observed between RWT and either blood pressure or urinary cortisol levels in patients with CS. Instead, RWT correlated significantly with disease duration, indicating that prolonged exposure to glucocorticoid excess, rather than hormone levels or hemodynamic load, is the primary determinant of concentric LV remodeling. Postoperative echocardiography showed normalization of RWT in five of six patients previously affected, reinforcing the concept of reversible myocardial structural changes following correction of hypercortisolism [14].

Conclusions

CS represents a rare but clinically important etiology of heart failure with preserved ejection fraction and, less commonly, dilated cardiomyopathy. Chronic hypercortisolism promotes systemic hypertension, LVH, diastolic dysfunction, myocardial fibrosis, and remodeling that may mimic infiltrative cardiomyopathies such as amyloidosis on echocardiography. GLS with apical sparing, although typically associated with amyloidosis, may also occur in cortisol-induced cardiomyopathy. Advanced imaging, including GLS, can detect subclinical myocardial impairment before overt systolic dysfunction develops. Notably, cardiac structural and functional abnormalities may partially or completely reverse following normalization of cortisol levels, highlighting the importance of early recognition and timely endocrine intervention. Clinicians should maintain a high index of suspicion for hypercortisolism in patients presenting with unexplained LVH, HFpEF, or atypical DCM, particularly when systemic features of CS are present. Future studies are needed to better characterize strain patterns in endocrine cardiomyopathies and to refine imaging-based algorithms for early detection.

References

  1. Uwaifo GI, Hura DE: Hypercortisolism. StatPearls [Internet]. StatPearls Publishing, Treasure Island (FL); 2024.
  2. De Leo M, Pivonello R, Auriemma RS, et al.: Cardiovascular disease in Cushing’s syndrome: heart versus vasculature. Neuroendocrinology. 2010, 92 Suppl 1:50-4. 10.1159/000318566
  3. Graversen D, Vestergaard P, Stochholm K, Gravholt CH, Jørgensen JO: Mortality in Cushing’s syndrome: a systematic review and meta-analysis. Eur J Intern Med. 2012, 23:278-82. 10.1016/j.ejim.2011.10.013
  4. Uzie Bło-Życzkowska B, Krzesinński P, Witek P, Zielinński G, Jurek A, Gielerak G, Skrobowski A: Cushing’s disease: subclinical left ventricular systolic and diastolic dysfunction revealed by speckle tracking echocardiography and tissue Doppler imaging. Front Endocrinol (Lausanne). 2017, 8:222. 10.3389/fendo.2017.00222
  5. Brosolo G, Catena C, Da Porto A, Bulfone L, Vacca A, Verheyen ND, Sechi LA: Differences in regulation of cortisol secretion contribute to left ventricular abnormalities in patients with essential hypertension. Hypertension. 2022, 79:1435-44. 10.1161/HYPERTENSIONAHA.122.19472
  6. Gladden JD, Linke WA, Redfield MM: Heart failure with preserved ejection fraction. Pflugers Arch. 2014, 466:1037-53. 10.1007/s00424-014-1480-8
  7. Owan TE, Redfield MM: Epidemiology of diastolic heart failure. Prog Cardiovasc Dis. 2005, 47:320-32. 10.1016/j.pcad.2005.02.010
  8. Pereira AM, Delgado V, Romijn JA, Smit JW, Bax JJ, Feelders RA: Cardiac dysfunction is reversed upon successful treatment of Cushing’s syndrome. Eur J Endocrinol. 2010, 162:331-40. 10.1530/EJE-09-0621
  9. Gill A, Dean N, Al-Agha R: Cushing’s, dilated cardiomyopathy and stroke: case report and literature review. Can J Gen Intern Med. 2016, 11:46-9.
  10. Klein AL, Oh J, Miller FA, Seward JB, Tajik AJ: Two-dimensional and Doppler echocardiographic assessment of infiltrative cardiomyopathy. J Am Soc Echocardiogr. 1988, 1:48-59. 10.1016/s0894-7317(88)80063-4
  11. Sahiti F, Detomas M, Cejka V, et al.: The impact of hypercortisolism beyond metabolic syndrome on left ventricular performance: a myocardial work analysis. Cardiovasc Diabetol. 2025, 24:132. 10.1186/s12933-025-02680-1
  12. Frustaci A, Letizia C, Verardo R, Grande C, Calvieri C, Russo MA, Chimenti C: Atrogin-1 pathway activation in Cushing syndrome cardiomyopathy. J Am Coll Cardiol. 2016, 67:116-7. 10.1016/j.jacc.2015.10.040
  13. Sugihara N, Shimizu M, Kita Y, et al.: Cardiac characteristics and postoperative courses in Cushing’s syndrome. Am J Cardiol. 1992, 1:1475-80.
  14. Fallo F, Budano S, Sonino N, Muiesan ML, Agabiti-Rosei E, Boscaro M: Left ventricular structural characteristics in Cushing’s syndrome. J Hum Hypertens. 1994, 8:509-13.

From https://www.cureus.com/articles/413845-global-longitudinal-strain-reduction-with-apical-sparing-in-cushing-syndrome-related-heart-failure-with-preserved-ejection-fraction-hfpef-a-case-report?score_article=true#!/

Filed under: Cushing's, pituitary, symptoms | Tagged: , , , , | Leave a comment »

Cushie 12-Step Program

Posted on December 4, 2025 by MaryO

I “acquired” this from another site and changed the names to protect the innocent…

As you know many of us Cushies have had or have an addiction to Googling.

I suggest anyone who feels compelled to google symptoms go to the message boards to ask for support instead of typing these or any words such as “buffalo hump” in the google search engine. When this is done all roads lead to one thing…… You Eat Too Much!; You’re Depressed!

So, anyone who is about to hit enter on their computer which feeds their Google addiction…. go to the message boards to ask for help. One of the other Cushies who have achieved “Google sobriety” will help you down of the ledge.

1. Admit for now that you are powerless over your urge to Google.
2. Believe that a power greater than you (that would be other Cushies) can help you off that ledge
3. Decide to turn your “fingers” over to a higher power as you understand it.
4. Make a searching and fearless inventory of what you hope to gain from googling.
5. Admit to yourself and to another human being the exact nature of your addiction to Google.
6. Allow other Cushies to assist you when you are so scared you are thinking about googling symptoms.
7. Humbly ask for Xanax, Klonopin or Cortef in order to calm yourself from googling symptoms
8. Make a list of all the diseases you think you have or have had and survived and have a burning ceremony and then…. take a nap.
9. Cite all Google sites you have searched diseases on and delete them from your favorites/history.
10. When you start thinking….STOP….. do something else, like take an inventory of your test results.
11. Seek through prayer and/or meditation to improve your thought process. Do not travel to “OMG’ or “What if” land (this is a serious suggestion).
12. Having had a spiritual awakening as a result of these steps, carry this message to all your Cushie friends and anyone else you know who has a Google addiction.

13. Now I know there isn’t a 13th step, however, if you have noticed you are drinking too much wine or taking too many pills, please remember there are other 12 step programs for that, lol…

So, what about it – what are *your* suggestions to cure Google Addiction?

Filed under: Cushing's | Tagged: , , , | 3 Comments »

Identification of Endogenous Hypercortisolism and the Effect of Mifepristone Treatment in Patients With Difficult-to-Manage Diabetes: A Case Series

Posted on December 3, 2025 by MaryO
Endogenous hypercortisolism (Cushing syndrome) is a multisystemic disease characterized by a wide range of clinical signs and symptoms. Its heterogeneous presentation can cause significant diagnostic delays, and prolonged exposure to excess cortisol activity can contribute to cardiometabolic abnormalities such as diabetes. When diabetes remains unresponsive or only partially responsive to standard-of-care treatment, clinicians should consider hypercortisolism as a potential underlying driver.Despite the risks associated with hypercortisolism, guidance on identifying and managing it in patients with diabetes remains limited. This article presents a case series of 10 patients from a single practice who were screened for hypercortisolism because of difficult-to-manage diabetes and additional comorbidities. All patients were treated for hypercortisolism with mifepristone, resulting in significant clinical improvements including weight loss, improved glycemic control, and reduced medication needs.

This real-world case series highlights the importance of recognizing hypercortisolism as a differential diagnosis and a potential contributing factor to difficult-to-manage diabetes despite standard-of-care therapies. Addressing hypercortisolism with mifepristone can result in substantial clinical benefits.

This article contains supplementary material online at https://doi.org/10.2337/figshare.30351361.

PDF of article here.

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Cushing’s, Cancer and Other Serious Diseases

Posted on December 2, 2025 by MaryO

I was drawn to this blog post because the author mentioned that she had both Cushing’s and cancer, a kind of unusual combination.

1974 to Today: Seal it up
By Experience
I still haven’t heard what the consensus is on my aftercare: Cushing’s and Cancer. I don’t know what I will be expecting to feel like after surgery. My endocrinologist said that I should get sick after the surgery and need some kind of …
1974 to Today – http://1974totoday.blogspot.com/

I don’t usually comment on blog posts but I did on this one because we seem to share so much, disease-wise.

I said

Hi, I was drawn to your blog post because I have a blog with the same name, Cushings & Cancer.

I had my Cushing’s long ago and my cancer (kidney aka renal cell carcinoma) was 3 years ago but I sure know where you’re coming for.

My surgeon contacted my endo for the amounts of steroids during surgery (they came through the IV) then post-op, they kept cutting my dose in half until I was back down to normal.
Generally, you stress-dose after surgery if you feel like you have a flu coming on. Has your endo given you Cortef or another steroid to take for emergencies like this? Sometimes, they will give you an injectible to be faster acting.

Best of luck with the cancer surgery AND your Cushing’s.
MaryO

I sure hope that this isn’t a trend, Cushies getting cancer although I know of a couple others on the boards getting cancer.

I suppose Cushing’s doesn’t make us any more immune to other diseases but it seems like it should.

Haven’t we already “done our time”?

OTOH, I have a friend with a serious cancer (aren’t they all?)  who recently learned that she has a second, unrelated, cancer.  Makes you wonder sometimes.

What other diseases have you had in addition to your Cushing’s?

Filed under: Cancer, Cushing's, Rare Diseases | Tagged: , , , | Leave a comment »

Co-Occurrence of Endogenous and Exogenous Cushing’s Syndromes: Does “Double Cushing Syndrome” Really Exist? A Case Report

Posted on December 1, 2025 by MaryO

ABSTRACT

Double Cushing syndrome exists: exogenous steroid use can mask concurrent adrenal hypercortisolism. When symptoms persist and cortisol remains high after tapering or stopping prescribed glucocorticoids, an endogenous source is likely. Early recognition with ACTH testing, dexamethasone suppression, and adrenal imaging reduces misdiagnosis, favors timely surgery, and supports safe tapering.

1 Introduction

Cushing syndrome (CS) is a non-physiological increase in plasma glucocorticoids [1]. In most cases, the source of increased plasma glucocorticoids is caused by exogenous steroid administration, which is quite common, and about 1% of the world population is on long-term (more than 3 months) oral glucocorticoids [1, 2]. On the contrary, endogenous overproduction of glucocorticoids is rare, and annually, only two to eight per million people are diagnosed with endogenous CS [3]. The simultaneous occurrence of endogenous and exogenous CS is an exceptionally uncommon phenomenon. This dual manifestation has been reported in a few case reports, highlighting its rarity and the complex diagnostic and therapeutic challenges it poses [4, 5]. Therefore, in this study, we discuss a patient who presented with cushingoid features and was simultaneously diagnosed with both endogenous and exogenous CS or, as it is called, double CS.

2 Case Presentation

The patient was a 46-year-old male with a history of new-onset hypertension and recurrent deep vein thrombosis (DVT) who was referred to our endocrinology clinic with a chief complaint of hip pain and weakness of the lower limbs. In the past 3 years, the patient had been receiving 50 mg/day of oral prednisolone and inhalation powder of Umeclidinium and Vilanterol (62.5/25 μg/dose) because of respiratory complications that started after Coronavirus Disease 2019 (COVID-19) vaccination. After 3 months of corticosteroid treatment, he experienced DVT for the first time when he was started on rivaroxaban. However, while he was on treatment, the second DVT occurred 1 month before his referral, and therefore, rivaroxaban was changed to warfarin 5 mg/day.

The patient also mentioned weight gain with his body mass index (BMI) rising from 26 to 31 kg/m2, progressive weakness of proximal muscles, easy bruising, decreased libido, mood changes with mostly euphoric mood, and irritability during the last 2 years. Moreover, multiple osteoporotic fractures of ribs, clavicle, sternum, and lumbar vertebrae were added to his symptoms in the past 5 months. At that time, he underwent bone densitometry, which revealed osteopenia of the left hip with a Z-score of −1.3 and severe osteoporosis of total lumbar spine with a T-score of −3.9. He started taking calcium and vitamin D3 supplements and received a single injection of 750 μg/3 mL teriparatide 30 days before his referral to our center.

Two months ago, the patient gradually reduced the dosage of prednisolone by tapering the dose to 12.5 mg/day. However, a month later, the hip pain and muscle weakness worsened to such an extent that the patient was unable to walk. Due to his signs and symptoms, the patient was referred to our center for further evaluation of CS. The patient also mentioned a history of nephrolithiasis, new-onset hypertension, and lower limb edema, for which he was started on eplerenone 25 mg and furosemide 20 mg tablets once daily. In his family history, the patient’s mother had type 2 diabetes mellitus, and his two sisters had a history of nephrolithiasis. The patient did not mention any history of allergies to medications or foods. He was addicted to opium and had 15 pack-years of smoking, but he did not mention alcohol consumption.

Upon admission, the patient presented with a blood pressure of 150/83 mmHg, heart rate of 74 bpm, respiratory rate of 20/min, temperature of 36.5°C, oxygen saturation of 93%, and BMI of 31 kg/m2. He was sitting in a wheelchair due to weakness and severe pain in the hip. On physical examination, the patient showed the features of CS, including moon face, buffalo hump, central obesity, facial plethora, thin and brittle skin, acne, and purple stretch marks (striae) on the flanks (Figure 1). Proximal muscle weakness in the lower limbs with a muscle force grade of 4/5 and 3+ edema was also observed. Laboratory investigations are shown in Table 1.

Details are in the caption following the image

De-identified clinical photographs illustrating the Cushingoid phenotype. (A) Overall habitus with marked central (truncal) adiposity. (B) Rounded plethoric face (“moon facies”). (C) Relatively slender distal extremities compared with truncal obesity. (D) Dorsocervical fat pad (“buffalo hump”). (E) Upper thoracic/supraclavicular fat accumulation. (F) Protuberant abdomen with wide violaceous striae.
TABLE 1. Laboratory findings of case report.
Laboratory test Patient value (in-hospital) Patient value (follow-up) Reference range
On admission
Hemoglobin (g/dL) 16.6 13.6 13.5–17.5
Hematocrit (%) 49.5 42.1 42–52
WBC (white blood cells; 103/μL) 11.8 7.1 4.0–11.0
PLT (platelet count; 103/μL) 286 294 150–450
BUN (blood urea nitrogen; mg/dL) 10 11 7–18
Cr (creatinine; mg/dL) 0.9 0.9 0.7–1.3
ALP (alkaline phosphatase; IU/L) 1016 129 44–147
AST (aspartate aminotransferase; IU/L) 48 30 < 31
ALT (alanine transaminase; IU/L) 88 21 < 31
CRP (C-reactive protein; mg/dL) 31 3 < 5
ESR (erythrocyte sedimentation rate; mm/h) 63 24 < 15
Sodium (mEq/L) 148 141 136–145
Potassium (mEq/L) 4.8 4.3 3.5–5
FBS (fasting blood glucose; mg/dL) 97 89 80–100
TC (total cholesterol; mg/dL) 267 182 < 200
TG (triglyceride; mg/dL) 148 104 < 200
LDL (low-density lipoprotein; mg/dL) 138 98 < 130
HDL (high-density lipoprotein; mg/dL) 64 55 30–70
In hospital
Cortisol 8 a.m. fasting (μg/dL) 20.2 14.1 4.3–24.9
ACTH (adrenocorticotropic hormone; pg/mL) < 1 — 7.2–63.3
1 mg Overnight dexamethasone suppression test (μg/dL) 16.5 — < 1.8

3 Methods (Differential Diagnosis, Investigations, and Treatment)

Initially suspected of having exogenous-induced CS, the patient’s prednisolone was on hold for 3 days. Cortisol 8 a.m. fasting level, measured with Electrochemiluminescence (ECL) and adrenocorticotropic hormone (ACTH) test, was 20.2 μg/dL (585.4 nmol/L) and < 1 pg/mL, respectively. Due to the lack of suppression of serum cortisol despite not using oral glucocorticoids, the absence of adrenal insufficiency symptoms, and the fact that the patient’s symptoms remained unchanged during this period, co-occurrence of endogenous CS was suspected.

A 1 mg overnight dexamethasone suppression test was performed to confirm endogenous CS diagnosis, and the results were reported as 16.5 μg/dL (normal range < 1.8 μg/dL). Considering the possibility of an ACTH-independent CS, the patient underwent an abdominopelvic multidetector computed tomography (MDCT) of abdominopelvic with adrenal protocol, which revealed a well-defined lesion with an approximate size of 32.8 × 38.6 mm in the left adrenal gland with a radiodensity of 90 Hounsfield units and a normal right adrenal gland (Figure 2). Moreover, evidence of previous old fractures as multiple callus formation was seen involving the clavicles, sternum, bilateral ribs, ischium, and pelvic bones. Multilevel old stable compression fractures of thoracic and lumbar vertebral bodies were also present. The differential diagnoses were glucocorticoid secretory adrenal tumors, including adrenal cell carcinoma and lipid-poor adenoma. In order to rule out pheochromocytoma, 24-h urine catecholamines were measured, and the results were negative.

Details are in the caption following the image

Abdominopelvic multidetector computed tomography (MDCT) with adrenal protocol showing a well-defined lesion with an approximate size of 32.8 × 38.6 mm in the left adrenal gland; radiodensity 90 HU. (A) Transverse plane. (B) Coronal plane. (C) Sagittal plane.

Finally, the patient underwent left adrenalectomy and corticosteroid replacement therapy due to the suppression of the other adrenal gland. According to the post-operative pathological investigations, immunohistochemistry markers reported as negative chromogranin, positive melan-A and inhibin, less than 3% Ki-67 marker, and lipid-poor adrenal cortical adenoma without invasions were diagnosed (Figure 3).

Details are in the caption following the image

Immunohistochemistry of the adrenal lesion (all panels acquired with a 100× oil-immersion objective; 10× eyepiece; original magnification ×1000). (A) Positive inhibin, (B) Positive Melan-A, (C) Less than 3% Ki-67 marker, and (D) Negative chromogranin.

4 Results (Outcome and Follow-Up)

Within 3 months after the operation, the patient’s corticosteroid was tapered and then discontinued due to the normalization of the cortisone serum test (14.1 μg/dL). Proximal limb weakness and hip pain, which had deprived the patient of the ability to move, gradually improved so that he could walk easily and perform daily activities. The signs and symptoms related to CS, including the patient’s mood, skin signs, and general appearance, returned to normal. The patient has been followed up for 6 months after the surgery. The patient’s BMI decreased to 24 kg/m2, and he stopped his anti-hypertensive medications with a blood pressure of 100/60 mmHg without previously prescribed drugs. So far, the laboratory tests have been within the normal range, and he has no complaints (Table 1).

5 Discussion

The described case was diagnosed with a cortisol-producing adrenocortical adenoma accompanied by exogenous CS. CS is an uncommon clinical condition caused by prolonged exposure to increased cortisol levels, which can be due to endogenous or exogenous factors [6]. Endogenous CS is infrequent and is classified as ACTH-dependent (80% of cases) or ACTH-independent (20% of cases) [7]. In the ACTH-independent category, adrenal adenoma accounts for 60% of cases and only 12% of cases of endogenous CS [7, 8]. Exogenous CS mainly occurs due to prolonged administration of glucocorticoids, which are used to manage a broad spectrum of diseases such as inflammatory, autoimmune, or neoplastic disorders and are the most common cause of CS worldwide [9]. Multiple factors, including formulation, duration of administration, pharmacokinetics, affinity, and potency of exogenous glucocorticoids, affect the probability of exogenous CS, but all forms of glucocorticoids can induce CS [10].

In the setting of cushingoid clinical features with chronic administration of high-dose glucocorticoids, especially oral prednisolone, the probability of exogenous CS is remarkably high; therefore, CS diagnostic approaches suggest that the first step after confirmation of cortisol excess is ruling out exogenous glucocorticoid administration [7, 8, 10]. Therefore, the possibility of co-occurrence of endogenous CS with iatrogenic CS is extremely low, and the diagnosis requires high clinical suspicion [4].

Differentiating endogenous and exogenous CS based on clinical features can be challenging and far-fetched. However, a few points can help physicians distinguish between these two. First, exogenous CS symptoms tend to be more striking, while endogenous CS appears more gradually. Second, hypertension, hypokalemia, and features of androgen excess, such as acne and hirsutism, are more common in endogenous CS [4, 10]. In addition, endogenous CS should be suspected if the patient’s symptoms continue after corticosteroid discontinuation or if the serum cortisol level is high despite corticosteroid cessation. In our case, the patient had a high cortisol level despite stopping prednisolone for 3 days, and he did not have any symptoms of adrenal insufficiency despite stopping prednisolone suddenly. Consequently, it was suspected that glucocorticoids might come from an endogenous source. Because ACTH was suppressed concurrently with elevated cortisol, non-ACTH-dependent CS was suspected, and MDCT of abdominopelvic confirmed it.

So far, few similar cases of simultaneous endogenous and exogenous CS have been reported. The first case was a 23-year-old woman with juvenile idiopathic arthritis who was administered high doses of triamcinolone for 16 years [4]. The development of cushingoid features that favored endogenous CS, such as hirsutism and acne, strengthened the suspicion of endogenous CS, and a CT scan revealed hypercortisolism with a bulky and nodular left adrenal gland, and a double CS was confirmed [4]. The second case was a 66-year-old woman diagnosed with exogenous CS after consumption of Traditional Chinese medicine (TCM) for a year [5]. The cessation of TCM did not significantly improve her cushingoid features, and she developed additional CS complications, including hypertension, diabetes mellitus, and osteoporotic fractures over the next 8 years. CS workup revealed a right-sided adrenal adenoma, and after the adrenalectomy, her clinical cushingoid features markedly improved [5]. These cases suggest that exogenous and endogenous CS can exist simultaneously in the same person. Although it is very rare, it should be considered in a person who still complains of CS symptoms after corticosteroid cessation. We suggest clinicians evaluate the patients for the disappearance of exogenous CS symptoms after tapering and stopping glucocorticoids. If the symptoms remain, they should be evaluated for endogenous CS.

6 Conclusion

The co-occurrence of an endogenous CS in the setting of an exogenous CS is curious. The diagnosis is based on a high clinical suspicion. Clinicians should evaluate patients for symptom resolution after tapering and discontinuing corticosteroids. Clinical cushingoid features that do not resolve after discontinuing exogenous glucocorticoids and high cortisol levels despite discontinuing corticosteroids should raise clinicians’ suspicion of the co-occurrence of exogenous and endogenous CS.

Author Contributions

Reza Amani-Beni: investigation, methodology, writing – original draft, writing – review and editing. Atiyeh Karimi Shervedani: methodology, writing – original draft. Bahar Darouei: conceptualization, validation, writing – review and editing. Matin Noroozi: methodology, writing – original draft. Maryam Heidarpour: conceptualization, supervision, validation, writing – review and editing.

Acknowledgments

The authors have nothing to report.

Consent

Written informed consent was obtained from the patient to publish this report, including de-identified clinical photographs, in accordance with the journal’s patient consent policy.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that supports the findings of this study are available on request of the corresponding author. The data are not publicly available due to privacy restrictions.

https://onlinelibrary.wiley.com/doi/10.1002/ccr3.71419

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