A Case Of Iatrogenic Cushing Syndrome

MCPS Family Medicine ( Sample Question)

A 46 year old house wife , with known history of asthma attends with the complaints of gaining weight, puffiness of face and high blood pressure for last 2 months. Her asthma control is much better since the start of some hakim (Quack) treatment for the last 2 months. On  examination her BP is 170/95 mm Hg. Her recent blood work shows normal urine D/R , CBC, serum electrolytes, thyroid, renal and hepatic profile. Her fasting blood glucose is 130 mg/dl.

1. What is the most likely diagnosis?
2. What is the most likely cause for it?
3. List 6 relevant questions in the history that will further help in diagnosis?
4. List 6 important features in examination that you must note?
5. What would you do to investigate this patient?

Question Solved:




1. What is the most likely diagnosis?

Answer: Cushing Syndrome

2. What is the most likely cause for it?

Answer: Most likely cause is the steroid medication patient has started to take from hakim (quack) to treat her asthma.

3. List 6 relevant questions in the history that will further help in diagnosis?

Answer: Question to ask in clinical history include:

1. Energy level and feeling of excessive fatigue or body weakness
2. Menstrual history with any recent change in the pattern of cycle ( Absent periods or excess flow)
3. Has the patient noticed any excessive growth of body hair especially on face (hirsutism)
4. Any bruising on the skin or unusual or prolonged bleeding from minor wounds.
5. Any changes in mood and difficult controlling emotions. (Psychiatric manifestations of Cushing syndrome)
6. List of all the medicines she is taking now. ( she might be using other steroids for asthma too other than that given by hakim and may contribute to excessive steroid intake)

4. List 6 important features in examination that you must note?

Answer: Important physical signs to notice in a patient with suspected Cushing syndrome include:

1. Central obesity with a fat pad in the upper back or base of the neck.
2. Moon like facies
3. Thin arms and legs
4. Acne on face.
5. Hair loss on the scalp (baldness)  while having excess facial hair growth ( hirsutism)
6. Purple striae on the skin along with bruising.

5. What would you do to investigate this patient?

Answer: Although the cause for the Cushing syndrome is most probably the use of excess steroid medications the patient may be ordered to have following investigations done:

• 24 hrs urinary cortisol levels ( Increased) 
• Dexamethasone suppression test ( If cortisol secretion from body is not suppressed after taking low dose dexamethasone it means there is some tumor secreting excess cortisol in the body. 
• Lipid profile. ( May have increased cholestrol and triglycerides)