Difficulty identifying clinical signs of cushing

Demetris Mariannis; Carmel Halevy; Vassiliki Bravis; Einas Mohamed

doi:10.1530/endoabs.113.WG2.1

WG2.1

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Endocrine Abstracts (2025) 113 WG2.1 | DOI: 10.1530/endoabs.113.WG2.1

SFEEU2025 Society for Endocrinology Clinical Update 2025 Workshop G: Disorders of appetite and weight (4 abstracts)

Difficulty identifying clinical signs of cushing’s disease with concomitant glucagon-like peptide-1 receptor (GLP-1) agonist use

Demetris Mariannis ¹ , Carmel Halevy ¹ , Vassiliki Bravis ¹ & Einas Mohamed ²

Author affiliations

¹Imperial Healthcare College NHS Trust, London, United Kingdom; ²Imperial College Healthcare NHS Trust, Imperial College Healthcare NHS Trust, United Kingdom

Background: Cushing’s disease typically presents with a constellation of symptoms associated with hypercortisolism, including weight gain, hypertension and diabetes. Diagnosis may be challenging with concomitant use of weight loss medications, potentially masking the classical features of Cushing’s disease.

Case Presentation: A 53-year-old menopausal woman with a background of asthma presented with weight gain and a large neck lipoma. Her medications included hormone replacement therapy, Symbicort and prednisolone during asthma exacerbations. She was prescribed GLP1- agonist for weight loss by her endocrinologist. Her initial weight was 105 kg, and with semaglutide therapy, she achieved a weight of 85 kg and continuing to lose weight.

Investigations: 9 am Cortisol 326 nmol/l, ACTH 53.0 ng/l (RR<30) ONDST: cortisol 304 nmol/l, ACTH not done Midnight Salivary Cortisol: 3.8 nmol/l & 4.0 (RR <2.6) Midnight Salivary Cortisone: 28.8 nmol/l & 30.6 nmol/l (RR <18) LDST: 48-hour cortisol 207 nmol/l. ACTH not done HDDST - ACTH suppressed to 14 ng/l 24-hour urine cortisol - 113 & 206 nmol/day (RR 0-164) HbA1 c 33 mmol/mol (RR <48) MRI pituitary - 5 mm cystic pituitary microadenoma These findings suggest centrally driven hypercortisolemia. However, the patient did not exhibit classic clinical features of Cushing’s disease, including hypertension or hyperglycemia (HbA1 c 33 mol/mol), likely secondary to ongoing semaglutide use.

Management and Outcome: The case was discussed at the pituitary multidisciplinary team meeting with the impression of Cushing’s disease and given the presence of a target lesion that could be amenable to surgical intervention, the patient will undergo inferior petrosal sinus sampling prior to a neurosurgical consultation.

Conclusion: This case displays the diagnostic challenges in considering potential Cushing’s disease when the only presenting feature is obesity, which is being effectively managed with GLP-1 agonist therapy. Given the increasing use of GLP-1 agonist, clinicians should remain vigilant in considering Cushing’s disease even when classical features are absent.