We report the case of a 70 year-old-lady with a background of type 2 diabetes and hypertension who was admitted with a history of self-neglect. She had burns affecting her hands which she had sustained after falling asleep next to the fire five weeks previously. Over the preceding three months, the patient had also deteriorated in terms of self-care, appetite, mobility and control of her blood sugars.
On examination, the patient was noted to have severe ulcers affecting her abdominal fold and legs bilaterally, and multiple features of Cushingoid morphology (hirsuitism, abdominal striae, thin skin, buffalo hump, gross obesity). The patient was also found to have a dense peripheral neuropathy in the glove and stocking distribution and a proximal myopathy affecting her legs.
The patients investigations revealed evidence of Cushings Disease, since her cortisol was not suppressed by low dose dexamethasone, but did suppress after administration of high dose dexamethasone. MRI scan demonstrated no pituitary lesion, in keeping with its relatively low sensitivity. The patient was then started on Metyrapone and this led to clinical and biochemical improvement.
This case illustrates several interesting features of diabetes complicated by co-existent Cushings Disease. Cushings Disease contributed to her poor glycaemic control which led to impaired healing of her ulcers. The proximal myopathy combined with her obesity led to decreased mobility, self-neglect and contributed to pressure sore formation. Many patients with type 2 diabetes within our clinical practice are obese and are treated for this without questioning it any further. This case highlights that in patients like this a high clinical suspicion for Cushings Disease must be held.
06 - 07 Nov 2006
Society for Endocrinology