Cushing’s Disease Presenting With Severe Weight Loss, Anorexia and Refractory Psychotic Depression

In this paper we report an unusual case of Cushing’s disease presenting with psychotic depression, paranoia, anorexia leading to severe weight loss culminating in 18% of her body weight. Case: A 22 year old female admitted with first episode psychosis to her local hospital displaying psychotic depressive symptoms, low mood, severe anorexia and mood congruent delusions regarding food contamination. Clinical manifestations of Cushing’s were recognised: cushingoid facies, facial plethora, hirsutism with striae and proximal myopathy. The degree of weight loss (70kg to 57kg) and paranoid ideation surrounding food necessitated caloric supplementation parenterally. Laboratory indices notable for hypokalaemia of 2.7nmol/l, male range testosterone level of 10.7nmol/l, DHEAS>27.1umol and suppressed gonadotrophins. Urine Free Cortisol was >25 times normal. Late night salivary cortisol was 13.4nmol/L(<2.6nmol/L). ACTH was raised at 74.0pg/ml in keeping ACTH dependent Cushing’s. MRI pituitary showed a bulky pituitary. CRF testing and Inferior Petrosal Sinus Sampling both indicated pituitary dependent Cushing’s disease. Following Metyrapone therapy and nutritional treatment the patient condition improved. She proceeded to transphenoidal pituitary exploration. Intraoperatively a very soft central lesion was excised and neuropathology confirmed a corticotroph adenoma. Post-operative morning cortisol at day 3 was 31nmol/l indicating early remission. 3 months post-operative there was remarkable improvement in mood, weight, cessation of anti-psychotics with normal diet and return of menses. She remained severely hypocortisolaemic 6 months post-op Conclusion: Cushing’s disease may present with severe psychiatric manifestation and significant weight loss. Clinicians need to be vigilant of psychosis as the primary presentation of Cushing’s disease.