Zeer Almotazbellah M M, Noman Mahmoud, Zeer Zahraa M M, Attawneh Alaa, Bairmani Zinah A, Alfroukh Khadeejeh M A, Oweina Layth
Faculty of Medicine, Al-Quds University.
Endocrinologist at Augusta Victoria Hospital, Jerusalem.
Ann Med Surg (Lond). 2023 Jul 14;85(8):4161-4166. doi: 10.1097/MS9.0000000000001050. eCollection 2023 Aug.
Munchausen syndrome is known as a factitious disorder imposed on the self. Factitious Cushing's syndrome (CS) is a very rare form of Munchausen syndrome, presenting with varied clinical and biochemical features, making diagnosis challenging.
A 40-year-old female patient who worked as a registered nurse presented with clinical features of CS but denied any exogenous corticosteroid use. The endocrine workup revealed that the patient had a high 24 h urinary-free cortisol collection before admission. Subsequent evaluations showed low levels of morning cortisol and plasma adrenocorticotropic hormone along with a suppressed overnight low-dose dexamethasone suppression test, leading to an investigation of hypercortisolism. Unexpectedly, subsequent testing showed a normal 24 h urinary-free cortisol level. Additionally, the patient was diagnosed with panhypopituitarism, the radiological investigations showed normal pituitary and adrenal glands. Despite consistently denying the use of corticosteroids, it was finally discovered that the patient had been surreptitiously taking prednisone and receiving multiple dexamethasone injections over the past few months. The patient received treatment through a gradual prednisone tapering regimen, accompanied by comprehensive psychiatric evaluation and management.
This case underscores the exceptional rarity of factitious CS and emphasizes the importance of considering it as a potential differential diagnosis in hypercortisolism cases, particularly when the patient's medical history contradicts investigative findings. Furthermore, it highlights the criticality of adopting a multidisciplinary approach to investigate patients whose clinical presentation aligns with factitious CS.
孟乔森综合征被认为是一种自我施加的做作性障碍。做作性库欣综合征（CS）是孟乔森综合征的一种非常罕见的形式，具有多样的临床和生化特征，这使得诊断具有挑战性。
一名40岁的女性注册护士患者表现出CS的临床特征，但否认使用过任何外源性皮质类固醇。内分泌检查显示该患者入院前24小时尿游离皮质醇水平升高。随后的评估显示早晨皮质醇和血浆促肾上腺皮质激素水平较低，同时过夜小剂量地塞米松抑制试验结果被抑制，从而引发了对皮质醇增多症的调查。出乎意料的是，随后的检测显示24小时尿游离皮质醇水平正常。此外，该患者被诊断为全垂体功能减退，影像学检查显示垂体和肾上腺正常。尽管患者一直否认使用过皮质类固醇，但最终发现该患者在过去几个月里一直在偷偷服用泼尼松并接受多次地塞米松注射。患者通过逐渐减少泼尼松用量的方案接受治疗，并伴有全面的精神科评估和管理。
该病例强调了做作性CS极为罕见，并强调在皮质醇增多症病例中，尤其是当患者的病史与检查结果相矛盾时，将其作为潜在鉴别诊断的重要性。此外，它突出了采用多学科方法对临床表现符合做作性CS的患者进行调查的关键性。
