Cushings syndrome

This is an online elog book to discuss our patients de-identified health data shared after taking his /her/ guardian informed consent here we discuss our individual patients problems through series of input from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

19 year old male resident of Nalgonda and currently studying intermediate ,came to opd with complaints of :

-Itchy Ring leisons over arms ,abdomen ,thigh and groin since 1 and half year .

-Purple stretch marks all over abdomen ,lower back ,upper limbs ,thighs since 1 year .

-Abdominal distension and facial puffiness since 6 months.

- Pedal edema since 3 months.

- Low back ache since 3 months .

- Feeling low , not feeling to talk to anyone.

- Weight gain and decreased libido since 3months.

- Loss of libido

HISTORY OF PRESENT ILLNESS :

Pt was apparently alright one and half year ago , when he slowly developed erythematous round leisons which are annular shaped and itchy all over abdomen , upper limb ,groin and inner thigh region .

No history of fever back then. No other complaints apart from skin lesions.

PAST HISTORY :

Pt visited local RMP where he prescribed auyurvedic medications and other creams ( unknown composition as pt don't have them currently ). He also prescribed tablets (unknown composition) . Patient started using all these medications for 1-2 months . 

Leisons reduced a bit after using medications .

Later after 2 months he developed multiple hyper pigmented plaques  over lower limbs ,abdomen , for which he again visited same place and used ayurvedic oils over the leisons.

He also used clobetasol ointment over the leisons.(for approximately 1 year all over the body) 

He started noticing pink striae over his abdomen first 1 year ago and later on back and over arms,which were gradually increasing in size .

Later he visited a hospital and used miconazole and luliconazole ointments also.

He used clobetasol ointment all over the leisons for long time .

He started noticing abdominal distension and facial puffiness ,weight gain, but never visited any hospital.

Later he developed pedal edema and low back ache since 3 months .

His consulted a dermatologist at this point of time who advised to consult physician and prescribed monteleukast , itraconazole tablets ,luliconazole  ointment for tenia corporis.

He stopped all medications one month ago and visited our opd with complaints of pink striae and easy fatigue ,weakness and low back ache .

His brother also gave history of pt being moody and feeling of low self esteem due to multiple leisons.

He even complaints pt wouldn't step out of house and always stays indoor and wouldn't interact with others .

No complaints of chest pain ,sob , palpitations .

No complaints of decreased urine output. 

No other negative history.

No h/o DM,HTN,TB,ASTHMA,CAD.

PERSONAL HISTORY:

Diet- mixed ( limited non veg) 

Appetite - normal

Bowel and bladder movements - regular

Insomnia

No addictions.

ALLERGIC HISTORY - pt gives h/o allergy to eggs ,brinjal .

VITALS: 

BP - 160/100 mmHg 

Pr - 96 BPM ,regular ,normovolemic .

Rr - 18/min 

Spo2- 98% on ra.

Weight - 63 kg.

Height - 175 cm.

GENERAL EXAMINATION : 

NO pallor ,icterus ,cyanosis , clubbing, lymphadenopathy.

Pedal edema present - pitting type extending upto knee.

Abdominal distension present.

Moon face present

Pink striae noted over anterior abdominal wall and on low back and on upper arms and thighs.

Thin skin present . 

Poor healing noticed over leg ulcers and easy bruising noted .

Acne present over face .

GYNECOMASTIA PRESENT .

neck pad of fat present 

 hair loss. 

.

Skin examination - Multiple itchy erythematous annular leisons noted all over abdomen , upper limb ,groin and inner thigh region .

Multiple hyperpigmented plaques noted over bilateral lower limbs .

SYSTEMIC EXAMINATION :

CVS - S1S2 heard .No murmurs 

RS - BAE present .

No adventitious sounds .

P/A - Soft , distended .

No organomegaly .

Bowel sounds present .

CNS - HMF - INTACT                                                        

TONE - NORMAL

Difficulty in getting up from chair was noticed.

PROVISIONAL DIAGNOSIS -

 ? IATROGENIC CUSHINGS SYNDROME . 

TINEA CORPORIS .

DENOVO HTN .

INVESTIGATIONS :

CBP - HB - 13.4 g/dl 

TLC - 6,800

PLT - 1.5 lakhs.

RBS - 139 mg/dl 

CUE - ALBUMIN - +1 

SUGARS - NIL .

PUS CELLS - 3-4 

RBC - NIL .

LFT - TB -1.03

DB-0.21

ALBUMIN - 3.9

RFT - UREA - 22 

SERUM CREATININE -0.6

ELECTROLYTES - NA - 136 

K- 4 

CL-98 

USG ABDOMEN - NORMAL.

ECG - SINUS TACHYCARDIA 

LVH PRESENT.

This was picture of striae one year ago when it gradually started :

On presentation to opd pictures : 28/05/21

Ecg: