General Hospital Psychiatry 36 (2014) 760.e9–760.e10

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Case Report

Adrenal Cushing's syndrome may resemble eating disorders Makiko Hatakeyama, M.D. a, Taku Nakagami, M.D., Ph.D. a, Norio Yasui-Furukori, M.D., Ph.D. b,⁎ a b

Department of Neuropsychiatry, Ohdate City Hospital, Ohdate, Japan Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan

a r t i c l e

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Article history: Received 5 January 2014 Revised 20 June 2014 Accepted 23 June 2014 Keywords: Adrenal Cushing's syndrome Eating disorder Depression Weight loss

a b s t r a c t We encountered a patient who presented extreme weight loss and received an eating disorder diagnosis that was later identified as adrenal Cushing's syndrome. A 32-year-old woman with a 2-year history of an eating disorder was admitted to our psychiatric ward due to dehydration, malnutrition and low weight. Her height and body weight were 152.1 cm and 29.8 kg, respectively (body mass index: 12.8). Her other symptoms included a depressed mood, decreased interest, retardation and suicidal ideation. Standard medical cares were prescribed to treat the depressive symptoms and eating disorder, but the depressive episode and low body weight of the patient persisted. Computed tomography of the abdomen revealed an unexpected left adrenal gland tumor. Cushing's syndrome was diagnosed based on several endocrinological examinations. After an enucleation of the left adrenal gland tumor, the patient began eating, and her body weight increased gradually. Her body weight increased to 42.0–47.0 kg (body mass index: 18.2–20.3). Her mental and physical conditions had stabilized. This case suggests that adrenal Cushing's syndrome may resemble eating disorders. © 2014 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

1. Introduction

2. Case report

Eating disorders are characterized by significant disturbances in eating behaviors accompanied by distress or excessive concern over body shape or weight. A variety of presentations are observed, but these disorders often appear with severe medical or psychiatric comorbidities [1–2]. Associated medical illnesses include brain tumors and other malignancies, gastrointestinal disease, and acquired immunodeficiency syndrome (AIDS). Cushing's syndrome is a clinical condition that results from chronic exposure to excessive levels of glucocorticoids. The subsequent hypercortisolism contributes significantly to the early development of systemic disorders through direct and/or indirect effects. The complications of this syndrome, which include obesity, hypertension, diabetes, dyslipidemia, and hypercoagulability, cause premature atherosclerosis and increase cardiovascular mortality. Impairment of the skeletal system is a relevant source of both morbidity and disability in these patients, especially considering the high prevalence of vertebral fractures [3–5]. In addition, muscle weakness, emotional lability, depression, and an impaired quality of life are common. [3–5]. We encountered a patient who presented extreme weight loss and received an eating disorder diagnosis that was later identified as adrenal Cushing's syndrome.

A 32-year-old woman presented to us with dehydration, malnutrition and low weight. She had a 2-year history of an eating disorder. She suffered from weight loss, a decreased appetite and amenorrhea, and she had remained indoors in her home for the previous 2 years. Due to a deterioration of her physical and mental condition, she had been admitted to the psychiatric ward and received tubal feeding 6 months prior. She was admitted to our psychiatric ward immediately. Her height and body weight were 152.1 cm and 29.8 kg, respectively

⁎ Corresponding author. Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki 036-8562, Japan. Tel.: + 81 172 39 5066; fax: + 81 172 39 5067. E-mail address: [email protected] (M. Hatakeyama).

Fig. 1. Computed tomography scan, revealing a 30-mm lesion in the left adrenal gland.

http://dx.doi.org/10.1016/j.genhosppsych.2014.06.006 0163-8343/© 2014 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

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M. Hatakeyama et al. / General Hospital Psychiatry 36 (2014) 760.e9–760.e10

Fig. 2. Changes in weight before and after the operation.

(body mass index: 12.8). Her other symptoms included a depressed mood, decreased interest, retardation, and suicidal ideation, but she did not present an intense fear of gaining weight. Antidepressants, antianxiety drugs and standard psychotherapy were prescribed to treat the depressive symptoms, but the depressive episode and low body weight of the patient persisted. She fell from the second floor of the hospital 5 months after admission. In addition to a left traumatic pneumothorax, hemorrhagic shock developed. Urgent computed tomography of the abdomen revealed not only a pelvic bone fracture but also an unexpected left adrenal gland tumor (Fig. 1). This finding led to minute endocrinal examinations throughout the body after the patient reached a stable state. Her symptoms were moon face, hypertension, proximal muscle weakness and red skin. However, neither central obesity nor fat redistribution was observed. Endocrinological tests revealed that her adrenocorticotropic hormone (ACTH) and cortisol levels were b 2.0 pg/ml and 21.2 μg/dL in the early morning and b 2.0 pg/ml and 17.8 μg/dL at night, respectively. In addition, hormone load examinations were performed, including the dexamethasone suppression test. These results failed to reveal a suppression of the 20.1 μg/dL cortisol level after dexamethasone (0.5 mg) was administered. In addition, no changes in cortisol levels were observed after a corticotropin-releasing hormone (CRH) loading test: 22.7 μg/dL at baseline, 22.7 μg/dL at 30 min, 22.6 μg/dL at 60 min and 20.9 μg/dL at 90 min after the CRH loading test. Based on these overall findings, Cushing's syndrome was diagnosed by an endocrinologist. An enucleation of the left adrenal gland tumor was carried out 8 months after admission. After the operation, the patient began eating, and her body weight increased gradually (Fig. 2). Menstruation resumed, and the depressive episode dissipated. Her body weight increased to 42.0–47.0 kg (body mass index: 18.2–20.3), and she was discharged from the hospital 18 months after the operation because her mental and physical conditions had stabilized. We confirmed that administering cortisol caused cortisol secretion to begin form 12 months after the operation with monitoring of cortisol and ACTH levels. 3. Discussion This case suggests that it is difficult to distinguish between adrenal Cushing's syndrome and an eating disorder. According to the DSM-IV-TR2, the diagnosis of an eating disorder depends upon the following criteria: 1) refusal to maintain body weight at or above a normal minimum weight for age and height or weight loss leading to the maintenance of body weight b85% of the expected level or failure to achieve an expected weight gain during a period of growth, leading to a body weight that is less than

85% of the expected weight; 2) intense fear of gaining weight or becoming fat, despite being underweight; 3) disturbance in the way one's body weight or shape are experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight; 4) amenorrhea (lasting at least three consecutive cycles) in postmenarchal girls and women. Amenorrhea is considered to be present when menstruation only occurs following the administration of hormones. Although three of these 4 criteria were met, an intense fear of gaining weight or becoming fat was not observed in our case. Accordingly, our patient was diagnosed with anorexia nervosa and received standard treatment for this condition, with little efficacy. After enucleation of the left adrenal gland tumor, the body weight of the patient recovered. Based on the clinical course, we concluded that her weight loss was the result of adrenal Cushing's syndrome and was not associated with an eating disorder. Recently, Sawicka et al reported a case similar to ours. A 26-year-old female had been treated for anorexia nervosa since she was 17 years old, and she had also been diagnosed with depression and paranoid schizophrenia [6]. After laparoscopic adrenalectomy, she was admitted to the hospital for 6 months, during which time she did not report any eating or mood disorders. In that case, it took approximately 9 years to make a correct diagnosis. Cushing's syndrome is usually associated with obesity; however, our patient suffered from extreme weight loss. We do not have a clear explanation for this discrepancy. Weight loss may be attributed to a severely depressed mood, which was most likely a consequence of the Cushing's syndrome. However, many of the depressive features observed in eating disorder patients may be secondary to the physiological sequelae of semistarvation. In conclusion, adrenal Cushing's syndrome may resemble an eating disorder. Physicians should remember to consider both of these diseases during diagnosis. References [1] Heaner MK, Walsh BT. A history of the identification of the characteristic eating disturbances of bulimia nervosa, binge eating disorder and anorexia nervosa. Appetite 2013;65:185–8. [2] Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. [3] Pereira AM, Tiemensma J, Romijn JA. Neuropsychiatric disorders in Cushing's syndrome. Neuroendocrinology 2010;92(Suppl 1):65–70. [4] Hudson JI, Hudson MS, Griffing GT, Melby JC, Pope Jr HG. Phenomenology and family history of affective disorder in Cushing's disease. Am J Psychiatry 1987;144:951–3. [5] Pollice C, Kaye WH, Greeno CG, Weltzin TE. Relationship of depression, anxiety, and obsessionality to state of illness in anorexia nervosa. Int J Eat Disord 1997;21:367–76. [6] Sawicka N, Gryczynska M, Sowinski J, Tamborska-Zedlewska M, Ruchala M. Two diagnoses become one? Rare case report of anorexia nervosa and Cushing's syndrome. Neuropsychiatr Dis Treat 2013;9:431–5.

Adrenal Cushing's syndrome may resemble eating disorders.

We encountered a patient who presented extreme weight loss and received an eating disorder diagnosis that was later identified as adrenal Cushing's sy...
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