Case Presentation: A 47-year-old woman with schizoaffective disorder and hypertension (HTN) was admitted to the psychiatry ward after found wandering her town. She was hypertensive and tachycardic. Psychiatric exam noted disorganization and appearance of responding to internal stimuli. Lisinopril was resumed for HTN. On hospital day (HD) 16, Medicine was consulted for persistent HTN, which responded poorly to multiple medications. On HD28, Cushing’s syndrome was considered given patient’s uncontrolled HTN, psychosis, hirsutism, hyperglycemia, moon facies, truncal obesity, edema, and history of amenorrhea. Initial work up included midnight cortisol, which was elevated. Psychosis can be associated with elevated cortisol levels1, so Endocrinology recommended outpatient follow up upon psychiatric stabilization. Patient’s mental health continued to deteriorate and ECT was initiated with minimal benefit. On HD68, Endocrine was formally consulted, who noted ECT can also cause elevated cortisol2. Further work-up revealed lab abnormalities and a pituitary macroadenoma on brain MRI, all consistent with Cushing’s disease.On HD87, patient underwent trans-sphenoidal resection of the pituitary mass. Post-operation, her cortisol levels normalized, and her mental health returned to baseline. Patient discharged home on HD103. After discharge, patient’s steroids, hyperglycemic regimen, and thyroid replacement were able to be tapered. Her BP remained controlled on two medications.
Discussion: Though this patient had many characteristics of Cushing’s syndrome, her diagnosis was significantly delayed due to her psychiatric decompensation, which was unresponsive to typical therapies. Patients with mental health diagnoses are also subject to higher rates of bias and health disparities, which potentially contributed to the delay in diagnosis3. Pseudo-Cushing’s syndrome, which can be seen in severe depression and psychosis, causes hypercortisolism and related features, but is not a true Cushing’s syndrome4. Urinary free cortisol excretion and dexamethasone suppression tests aid in ruling out Pseudo-Cushing’s5.
Conclusions: This case highlights the nuances of discerning Cushing’s disease from Cushing’s syndrome, particularly in the setting of acute psychiatric decompensation. A quarter of adult hospitals utilize hospitalists as co-managers on psychiatric units6. Hospitalists need to be aware of organic causes of recalcitrant psychotic disorders associated with other medical issues and of their own implicit biases in caring for patients with mental health disorders.
