A number of psychiatric conditions are associated with Cushings disease. Acute psychosis is rare. We describe a patient with sudden onset of florid psychosis who required medical and surgical treatment.
Case: A 38 year old woman previously well and employed in the financial sector was admitted to the acute psychiatric unit with delusional, disorganised and paranoid ideation. Despite management with olanzapine, haloperidol and benzodiazepines her mental state deteriorated. She was noted to be centrally obese and hirsuite with multiple bruises. DEXA scanning revealed osteopaenia in the lumbar spine, normal BMD in the femoral neck. 9 am serum cortisol 907 nmol/l (138690), ACTH 55.6 ng/l (952), urinary cortisol >2000 nmol/l (97331). Cortisol failed to suppress during an overnight 1 mg dexamethasone suppression test (DST) (9 am cortisol 503). During an intravenous DST (1 mg/hr for 5 hours) cortisol did not suppress after 24 hours (695 to 852 nmol/l). MRI pituitary revealed a 3 mm right sided pituitary adenoma with no optic chiasm compression. Initiation of ketoconazole led to deranged LFTs. After 3 weeks of aminoglutethimide and metyrapone there was an improvement in symptoms. During this time she became extremely hypertensive and after 6 successive grand-mal seizures was admitted to ICU. ACE-I, B-blockers, Ca channel blockers, nitrates and spironolactone were required. General anaesthesia was required for inferior petrosal sinus sampling and revealed a 4 fold greater central:peripheral ACTH gradient. Cushings disease was diagnosed. Transphenoidal hypophysectomy was successful with evidence of adenoma. Post-operative transient diabetes insipidus was treated with DDAVP. Repeat urinary free cortisol 32 nmol/l. She currently requires only cortisone acetate 12.5 mg bd and has restarted part-time work.
Discussion: Late-onset schizophreniform psychosis associated with hypertension and central obesity raises the suspicion of Cushings syndrome. Management may be difficult and take months for symptom resolution.
01 - 05 Apr 2006
European Society of Endocrinology