A case of cyclical cushing

Malgorzata Lubczynska; Kiran Rathi; Haider Imitiaz; Jumaah i Al; Arjun Raj; Emma Bremner; Emily Jaques-Davis; Saraa Abdinor; Mary Barrowcliffe; Narendra Reddy; Shailesh Gohil; Levy Miles J.

doi:10.1530/endoabs.109.P47

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Endocrine Abstracts (2025) 109 P47 | DOI: 10.1530/endoabs.109.P47

SFEBES2025 Poster Presentations Adrenal and Cardiovascular (61 abstracts)

A case of cyclical cushing’s disease: a diagnostic conundrum of investigations and management

Malgorzata Lubczynska , Kiran Rathi , Haider Imitiaz , Ali Al Jumaah , Arjun Raj , Emma Bremner , Emily Jaques-Davis , Saraa Abdinor , Mary Barrowcliffe , Narendra Reddy , Shailesh Gohil & Miles J. Levy

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University Hospitals of Leicester, Leicester, United Kingdom

Cyclical Cushing’s syndrome is a rare condition marked by intermittent episodes of cortisol excess (peaks) followed by normal cortisol levels (troughs). We report a 51-year-old woman admitted to the University Hospitals of Leicester for urgent plastic surgery following deliberate self-harm. She presented with severe myopathy, a Cushingoid appearance, and psychosis. Laboratory tests showed urine cortisol >1000 nmol/l, serum cortisol 1656 nmol/l, potassium 2.4 mmol/l, and ACTH 200 pmol/l. Treatment with metyrapone resulted in significant symptom resolution within a month. A review of laboratory results from the referring hospital showed the patient’s cortisol levels followed a cyclical pattern (1749, 489, 925, 178 nmol/l). In May 2024, before transferring to UHL, she was admitted to her local hospital with an acute abdomen requiring a colectomy, likely due to pseudo-obstruction from the severe hypokalaemia. Her cortisol level was 1749 nmol/l, and ACTH was 211 pmol/l, indicating ACTH-dependent Cushing’s syndrome. The patient underwent CT whole body, MRI pituitary, FDG-PET, octreotide scan, and 68-Ga-DOTATAE PET scans. Aside from bilateral adrenal hyperplasia, consistent with ACTH-depended Cushing’s, no significant focal uptake to suggest a primary lesion was observed. She went on to have inferior petrosal sinus catheter sampling (IPSS) which showed no significant central versus peripheral gradient after desmopressin stimulation of ACTH. The patient continues to do well off metyrapone. As part of a multi-centre cyclical Cushing’s study, she is collecting twice-weekly late night salivary cortisol and having weekly post 1 mg dexamethasone suppression salivary cortisol levels assessed, as well as hair cortisol. Overt cyclical Cushing’s syndrome is a rare and difficult clinical problem. It is likely that in Cushing’s syndrome per se there is some cyclicity of cortisol. The need to investigate this condition has led to a multi-centre study and we hope to publish on this in due course.