Early screening for underlying causes of obesity before weight loss surgery, including Cushing’s syndrome in individuals with suggestive signs, can help improve outcomes and reduce unnecessary procedures.
That’s according to a report describing a case of a woman in Saudi Arabia who underwent a failed bariatric surgery and was eventually diagnosed with Cushing’s syndrome caused by a tumor in the adrenal gland.
“Timely diagnosis and proper management are important, as they can significantly improve outcomes, prevent unnecessary interventions, and reduce the risk of long-term complications,” the researchers wrote.
Report, “Cushing’s Syndrome Secondary to Adrenal Adenoma Diagnosed After Failed Bariatric Surgery: A Case Report,” was published in Case Reports in Endocrinology.
Cushing’s diagnosis was missed at first presentation
Cushing’s syndrome refers to a condition caused by excessive production of the hormone cortisol. In some cases, it is caused by a tumor in the pituitary gland that produces excess adrenocorticotropic hormone (ACTH). This special type of syndrome is known as Cushing’s disease. ACTH triggers the adrenal glands, located above the kidneys, to produce cortisol.
The syndrome can also arise from an ACTH-secreting tumor located outside the pituitary gland – called ectopic Cushing’s syndrome – or from an adrenal tumor that directly produces excess cortisol (independent of ACTH).
Cushing’s diagnosis after bariatric surgery has emerged as a clinical problem, leading to complications such as weight loss and inadequate mortality.
Here, a duo of researchers in Saudi Arabia described the case of a 26-year-old woman diagnosed with Cushing’s syndrome caused by an adrenal tumor after bariatric surgery, a weight loss procedure.
A woman who has progressively gained weight since she was 20, and developed high blood pressure, or hypertension, and diabetes at the age of 22. Despite undergoing a sleeve gastrectomy – a bariatric surgery to remove most of the stomach – and adhering to a healthy diet and exercise, she only lost 15 kg (about 33 lbs) over a year, with continued hypertension and diabetes.
According to the researcher, in retrospect, he had the classic signs of Cushing’s before the operation, “but this diagnosis was missed in his first presentation.”
Women have the classic signs of excessive cortisol production
Physical examination reveals a round face with acne, thick facial hair, thin hair on the head, fat accumulation between the shoulder blades and around the abdomen, wide purple stretch marks, and easy bruising. She also reported that her menstrual period had been over for a year.
Laboratory work shows excess cortisol, or hypercortisolism, as well as low-normal levels of female reproductive hormones and elevated levels of testosterone (male sex hormone). Also, the low-dose dexamethasone suppression test, which is used to assess excessive cortisol production, fails to suppress cortisol levels despite reducing ACTH levels, suggesting ACTH-independent Cushing’s.
Imaging tests revealed the presence of tumors in both adrenal glands, with the largest nodule located in the right adrenal gland. She was also given low bone density – a condition in which bones have low mineral content, decreasing bone strength.
This case highlights should be considered [Cushing’s] both before bariatric surgery, especially in patients with some features of hypercortisolism, and in patients with poor results after bariatric surgery.
The woman underwent surgery to remove her right adrenal gland through a minimally invasive procedure. Postoperatively, his cortisol levels were below normal, indicating adrenal insufficiency, and he began hydrocortisone replacement therapy.
Four months after the surgery, the woman experienced an additional weight loss of 10.5 kg (about 23.15 lbs), normalization of blood pressure, and a significant decrease in blood sugar levels. Her menstrual cycle became regular after one year, and she was able to stop all antihypertensive and antidiabetic medications. After an additional year, he also stopped hydrocortisone replacement therapy.
“This case highlights the need to consider [Cushing’s] both before bariatric surgery, especially in patients with some features of hypercortisolism, and in patients with poor results after bariatric surgery,” wrote the researchers.
“Although rare, it is a reversible and treatable cause of obesity that should not be dismissed when clinical features are suggestive,” they added.
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