ISSN ONLINE: 2558-815X
ISSN PRINT: 1584-9244
ISSN-L: 1584-9244

Pitfalls of long-term hirsutism as central feature of Cushing’s disease without indentification of a pituitary mass on a menopausal woman


Introduction: Tumor-related hirsutism may be caused by an Adrenocorticotropin (ACTH) dependent Cushing’s syndrome (CS) despite heterogeneous presentation.

Case report: A 57-year female, known with impaired glucose tolerance, was admitted for longtime progressive hirsutism and recently changed characteristics, in association with asthenia, headache, changes in mood, depression, sleep disturbances, weight gain. Specific laboratory test confirmed ACTH-dependent CS but no tumor mass was highlighted on pituitary Magenetic Resonance Imagery, neither was at abdominal, ovarian and thoracic Computed Tomography scan. Hormonal tests revealed high total testosterone for a postmenopausal woman and slightly elevated levels of 17-hydroxyprogesterone in addition to increased HOMA index, suggestive for insulin resistance. Since no underlying mass was identified, a conservative approach was initially offered to the patient: 400 mg daily ketoconazole alongside 1500 mg daily metformin, diet, exercise in order to weight loss. Further changes of the management are needed.

Conclusion: ACTH – dependent Cushing’s syndrome is usually accompanied by hirsutism into larger frame of cardio-metabolic comorbidities. Hirsutism features may change over time and this may be suggestive for an additive cause to otherwise idiopathic type. Another particular aspect is mild Cushing’s disease without tumor imagery identification. Hypophysectomy under these circumstances is challenging and medical therapy should be tried first until a definitive therapeutically solution is done.

Abbreviations: mg = miligram, ACTH = Adrenocorticotropic Hormone, BMI = Body Mass Index, CS= Cushing’s syndrome, CT = Computed Tomography, DHEA-S= Dehydroepiandrosterone Sulfate, DXM = dexamethasone, FT4 = Free Thyroxine, HAIRAN = Insulin-Resistant Acanthosis Nigricans, MRI = Magnetic Resonance Imaging, SHBG = Sex Hormone-Binding Globulin, TSH = Thyroid Stimulating Hormone

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