A 49-year-old man with a 10-year historical past of sort 2 diabetes presents with progressive proximal muscle weak spot and debilitating fatigue that started 1 yr prior, as described in a case examine offered on the American Academy of PAs 2021 Convention (AAPA 2021). The affected person has a 10-year historical past of sort 2 diabetes and previous medical historical past of hypertension, hip fracture, idiopathic vascular calcification, deep vein thrombosis (DVT), and separate left ulnar arterial thrombosis.
His historical past of DVT and ulnar arterial thrombosis are considered secondary to issue V Leiden, which is optimistic in his household as is sort 2 diabetes. He’s a nonsmoker and denies illicit drug use. Drugs embrace aspirin, apixaban, amlodipine, candesartan, metformin, sitagliptin, and atorvastatin.
Bodily Examination and Laboratory Findings
On bodily examination, he seems fatigued. He’s 5’9” tall and weighs 186 lb. Important indicators and irregular findings on bodily examination are proven in Tables 1 and a couple of.
Desk 1. Important Indicators
|Pulse, beats per minute||88|
|Respiratory price, breaths per minute||12|
|Blood strain, mm Hg||110/64|
Desk 2. Irregular Findings
|Gentle facial plethora|
|Supraclavicular fats pads|
|Skinny pores and skin|
|Central weight problems|
|Pink stomach striae|
|Bilateral proximal muscle energy, 4/5|
|Left hand energy, 3/5|
Laboratory exams for full blood depend, metabolic panel, thyroxine (T4), and thyrotropin are regular, though he has delicate neutrophilia (not a brand new discovering). His urinalysis is regular aside from presence of glucose. His glycated hemoglobin A1c (HbA1c) is 6.7%.
Secondary Causes of Diabetes
Whereas most circumstances of diabetes are sort 1 or sort 2, different much less widespread varieties generally known as secondary causes of diabetes could happen. Secondary diabetes could also be related to being pregnant (gestational), power pancreatitis, glucocorticoid use, and different endocrinopathies comparable to pheochromocytoma, acromegaly, and Cushing syndrome.
The affected person is suspected of getting Cushing syndrome and underwent endocrine analysis (Desk 3), which demonstrates excessive ranges of 2-hour urine free cortisol, salivary cortisol, and plasma adrenocorticotropic hormone (ACTH), in addition to failure to suppress morning plasma cortisol,
Desk 3. Endocrine Analysis
|24-hour urinary free cortisol||86 mcg (nl <45)|
|Salivary cortisol (at 11:00 pm)||518 ng/dL (nl < 100)|
|Low-dose in a single day dexamethasone||Check reveal failure to suppress morning plasma cortisol: 19.85 mcg/dL (nl <1.8)|
|ACTH||169 pg/mL (nl <63)|
|Insulin-like development factor-1||Regular|
|Follicle stimulation hormone||Regular|
ACTH, adrenocorticotropic hormone; Micrograms, mcg; nanometer per deciliter, ng/dL; regular laboratory discovering, nl; micrograms per deciliter, mcg/dL; picograms per milliliter, pg/mL.
Diagnostic Imaging and Therapy
Magnetic resonance imaging (MRI) with gadolinium distinction of the pituitary gland demonstrates a sellar mass measuring 11 x 16 mm.
As a result of COVID-19 pandemic, surgical procedure is delayed till 3 months after a pituitary macroadenomas analysis. Tumor resection by endoscopic endonasal trans-sphenoidal hypophysectomy reveals a 1.1-cm corticotroph pituitary adenoma; it stains optimistic for radiolabeled ACTH confirming the supply of autonomous ACTH secretion.
Comply with-Up After Pituitary Surgical procedure
After surgical procedure, his plasma cortisol fell from >20 mcg/dL to 4.2 mcg/dL. 5 months post-surgery, his HbA1c decreased from 6.7% to five.6% with weight lack of 35 lb (186 lb to 151 lb).
Concluding Case Feedback
“On this case, it’s unknown whether or not Cushing syndrome supervened on this affected person with diabetes or if Cushing syndrome alone was current from the start,” famous examine authors Jeffrey Vasiloff, MD, and Melissa Bowlby, PA-C, who’re each school members within the Division of PA Apply, School of Well being Sciences and Professions of Ohio College in Dublin, Ohio.
“Whereas sort 2 diabetes is predicted to progress, it’s paramount for clinicians to think about concurrent or different etiologies when atypical scientific options seem. Right here, remedy of Cushing syndrome led to marked enchancment in diabetes,” they concluded.
- Bowlby M, Vasiloff J. Uncommon reason behind diabetes: a case examine. Poster offered at: American Academy of PAs 2021 Convention; Might 23-26, 2021. Poster 136.