SHM Converge Scientific Abstract ePoster Gallery-Primary Cushing's Disease in a Patient With Acute Psychiatric Decompensation

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A 47-year-old woman with schizoaffective disorder and hypertension was admitted to a psychiatric unit with severe psychotic decompensation, persistent tachycardia, and poorly controlled blood pressure. Over the course of a prolonged hospitalization, she developed multiple features suggestive of Cushing’s disease, including hirsutism, hyperglycemia, moon facies, truncal obesity, edema, and a history of amenorrhea.  <br /><br />At first, her symptoms were attributed to psychiatric illness, and outpatient endocrine follow-up was recommended after stabilization. However, her mental status continued to worsen despite treatment, and electroconvulsive therapy provided minimal benefit. Endocrinology later became formally involved and recognized that the patient’s presentation could reflect true hypercortisolism rather than pseudo-Cushing’s syndrome, which can occur in severe depression or psychosis.  <br /><br />Further evaluation showed markedly abnormal endocrine labs, including very high serum and urine cortisol, elevated ACTH, elevated DHEA, suppressed prolactin, suppressed TSH and free T4, and failure to suppress cortisol on dexamethasone testing. Brain MRI revealed a pituitary macroadenoma, confirming primary Cushing’s disease. The patient underwent transsphenoidal resection of the pituitary tumor on hospital day 87.  <br /><br />After surgery, cortisol levels normalized and her psychiatric symptoms returned to baseline. She was discharged home on hospital day 103, with gradual tapering of steroids, diabetes treatment, and thyroid replacement. Her blood pressure remained controlled on two medications.  <br /><br />This case emphasizes how Cushing’s disease may be missed in patients with acute psychiatric illness, especially when symptoms overlap with pseudo-Cushing’s syndrome. It also highlights the importance of considering organic causes of refractory psychiatric symptoms and remaining alert to diagnostic bias in patients with mental health disorders.

Asset Subtitle

Elise Haupt

Meta Tag

Author List Ashley Viere, Elise Haupt

Category Clinical Vignettes

Concept Cushing Syndrome

Concept Cushing disease

Concept Pseudo-Cushing Syndrome

Concept Hypertension

Concept Hyperglycemia

Distinguished Non-Finalist

Presenter Organization Regions Hospital HealthPartners

Presenting Author Elise Haupt

Track Adult

Keywords

Cushing’s disease

schizoaffective disorder

hypercortisolism

pituitary macroadenoma

pseudo-Cushing’s syndrome

psychosis

transsphenoidal resection

ACTH

hypercortisolism diagnosis

psychiatric decompensation

Cushing Syndrome

Cushing disease

Pseudo-Cushing Syndrome

Hypertension

Hyperglycemia