December 25, 2024

56-year-old woman with alcoholic liver disease presents complains of being tired

By Med-Challenger · 2 minute read

A 56-year-old woman with alcoholic liver disease presents to you with the complaint of being tired but states that she is otherwise healthy. She currently drinks 3 six-packs of beer every day and tells you she is not interested in alcohol cessation.

On examination, her height is 5 feet 6 inches, she weighs 186 pounds, and her blood pressure is 147/84 mm Hg. She has a buffalo hump and striae in the abdomen that are pink in color. She is able to stand up after squatting.

Her nonfasting, finger-stick blood glucose test result is 189. On initial work-up, you order a morning cortisol level, which is 16 mg/dL, and a glycated hemoglobin level, which is 7.3%.

You confirm a diagnosis of diabetes but you are concerned the patient may have Cushing syndrome given her elevated cortisol level. You order a dexamethasone suppression test (1 mg), which comes back as 14 mg/dL.

Which of the following statements is true of patients with pseudo-Cushing syndrome associated with alcohol abuse?

Chronic alcohol use results in a physiological decrease in serum cortisol levels
Patients with pseudo-Cushing syndrome secondary to alcohol abuse require the same treatment as patients with Cushing syndrome
Cortisol levels in pseudo-Cushing syndrome remain high even after a period of abstinence
The symptoms of pseudo-Cushing syndrome are often indistinguishable from those of Cushing syndrome

The correct answer is:

The symptoms of pseudo-Cushing syndrome are often indistinguishable from those of Cushing syndrome

This patient is likely to have pseudo-Cushing syndrome. Depression, obesity, and alcoholism are all conditions that can lead to this diagnosis. It is important to make an appropriate diagnosis to avoid treating a patient who does not have true Cushing syndrome and an endocrinologist can provide advice on appropriate testing. Ideally, tests need repeating following a period of abstinence, as abstinence usually results in complete resolution of the physiological increase in serum cortisol levels. The symptoms of pseudo-Cushing syndrome are often indistinguishable from that of Cushing syndrome.

Reference:

Alwani RA, Schmit Jongbloed LW, de Jong FH, et al. Differentiating between Cushing's disease and pseudo-Cushing's syndrome: comparison of four tests. Eur J Endocrinol. 2014;170(4):477-486.

Nieman LK. Cushing's syndrome: update on signs, symptoms and biochemical screening. Eur J Endocrinol. 2015;173(4):M33-8.

Nieman LK. Causes and pathophysiology of Cushing's syndrome. Updated May 2014, Accessed January 30th 2017.

McPherson RA, Pincus MR. Henry's Clinical Diagnosis and Management by Laboratory Methods. 23rd ed., 2016.

Stewart PM, Newell-Price JD. The adrenal cortex. In: Melmed S, Polonsky KS. Williams Textbook of Endocrinology. 13th ed., 2016: 489-555.

Yanovski JA, Cutler GB Jr, Chrousos GP, Nieman LK. The dexamethasone-suppressed corticotropin-releasing hormone stimulation test differentiates mild Cushing's disease from normal physiology. J Clin Endocrinol Metab. 1998;83(2):348-352.

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