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Psychiatric symptoms as a clinical presentation of Cushing's disease--case report--/Manifestari psihiatrice in boala Cushing --prezentare de caz--.

THE ACTUALITY OF THE PROBLEM

Cushing's syndrome includes a variety of signs and symptoms which are related to the longterm exposure of the body to excess glucocorticoids. Exogenous Cushing's syndrome, caused by the treatment of patients with immune and haematological diseases and cancer with glucocorticoids is frequently seen in daily medical practice. Endogenous Cushing's syndrome, caused by overproduction of cortisol by the adrenal gland is, however, rare. The incidence of endogenous Cushing's syndrome is around two to three cases per million inhabitants per year. Endogenous Cushing's syndrome can be caused by several disorders which are either driven by excess ACTH secretion from a pituitary adenoma, from a tumour located elsewhere in the body, which secretes ACTH ectopically, or by an ACTH-independent source, mostly primary benign or malignant adrenal tumours.

A patient with a full-blown clinical presentation of Cushing's syndrome is, in most instances, easily recognised by the moon face, plethora, ease of bruising, central obesity and muscle atrophy, together with a broad range of psychological and psychiatric disturbances, hypertension, diabetes mellitus, osteoporosis and an increased sensitivity to infections. It is well known that mortality in untreated patients with Cushing's disease is high. The most frequently encountered causes of death include sepsis, cardioand cerebro-vascular deaths, and suicide. One of the great disappointments is that even after successful initial treatment, many patients will suffer from important draw-backs in the long-term follow-up, including the complications of osteoporosis, hypertension, obesity, as well as persistent psychiatric problems (depression, mood dysregulation, sleep disturbance, cognitive abnormalities, anxiety, hypomania, confusion).

A successful diagnostic approach to a patient with suspected Cushing's syndrome requires experience, careful testing, excellent clinical chemistry and the application of strict criteria.

CASE REPORT

Reasons for hospitalization: In December 2005, a 32 year old male was admitted in the endocrinology department for oscillatory blood pressure values, central obesity with typical moon-face and abdominal striae. Also he associated major depression with psychotic features (depressed mood, anxiety and somatic complaints).

Physical examination showed obesity (with supraclavicular fullness and dorsocervical fat pad), thin skin which bruised easily, facial plethora, purple abdominal striae (1 cm wide) and muscle atrophy. His body mass index was 32 kg/[m.sup.2], heart rate--90 bpm and his blood pressure was 145/80 mm HG.

Laboratory: the blood tests revealed Hb-16 mg/dl, triglycerids--180 mg/dl. normal plasma cortisol level, with increased free urinary cortisol (350 mg/24 h).

Other lab examinations: the imagistic exams showed a normal lateral skull x-ray and a 5 mm left adrenal tumour on the abdominal CT. The patient was sent to surgery department, where left adrenalectomy was performed (AP exam - difuse and nodular hyperplasia).

During this period, he suffered three surgical interventions on his adrenal glands and two transsphenoidal resections, his psychiatric problems varying, depending on his cortisol values (as long as the values were in normal range, he had no symptoms, and when the cortisol level started to rise, the symptoms reappeared).

In the columns below, we summarized all the medical procedures this patient underwent, as well as his biochemical values of ACTH, plasmatic cortisol and urinary free cortisol (Table I).

DISCUSSION

Cushing's syndrome can present itself with a spectrum of symptoms; however, it is less recognised that psychiatric symptoms can be part of the clinical presenting features. During the investigations for an organic cause for a psychiatric illness, Cushing's syndrome needs to be considered, especially if there are other features such as hirsutism or hypertension. There has been considerable interest regarding the relationship of life events to physical and mental illness (1). It has not always been easy to establish causal links between the three variables (life event, physical illness, and mental illness), since, in theory, any variable could influence the remaining two. Therefore, at the time of diagnosis and treatment of Cushing's syndrome, the nature and significance of a life event in the distant past may not be correctly appreciated. Estimates of the frequency and severity of psychiatric illness have varied in reported series. Starr noted "personality change" in 53 patients with Cushing's syndrome as follows--21 were normal or had minimal changes, 19 had severe or moderately severe changes, and 13 patients had very severe changes (2). Trethowan and Cobb in an unselected series of 25 patients noted a "galaxy of mental symptoms", but that "no single clear-cut psychiatric picture emerged" (3). Soffer et al noted "mental disturbances" in 40% of 50 patients with Cushing's syndrome (4); these authors reviewed the literature and found "mental changes" in 46% of patients with Cushing's syndrome (5). Ross et al. noted "psychological difficulty" in 40% of 50 patients (6).

Jeffcoate et al. reported "psychiatric abnormalities" in 65% of 38 patients with Cushing's syndrome (7). Cohen, in 1980, reported "distinct affective disorders" in 86% of 29 patients with Cushing's syndrome (8). Starkman et al found a wide range of symptoms in 35 patients with Cushing's syndrome, rating the "psychiatric disability" as mild in 34%, moderate in 26%, severe in 29% and very severe in 11% of the cases (9). Haskett reported that 83% of 30 patients with Cushing's syndrome met strict diagnostic criteria for affective disorders, including depression, mania and hypomania (10). Starkman et al reported anxiety in 66% of 35 patients (11), and Loosen et al noted generalized anxiety disorder in 79% of 20 patients (12). There are cases reported in which Cushing syndrome presented itself as a schizophrenia-like psychotic state (13) or depressive syndrome with psychotic features (auditory hallucinations and nihilistic delusions) (14).

In the case, we presented the patient presented at the hospital with major depression with psychotic features, manifesting a depressed mood, anxiety and somatic complaints. There was a gradual decline in the mental state in the last two months and a background of no previous psychiatric diagnosis. By six weeks post first surgery (left adrenalectomy), his psychosis had resolved and the patient was stabile till May, 2006, when the symptoms reappeared (sleep disorder, depressed mood). We performed another surgical resection of the remaining adrenal tissue and again, after one month, the symptoms disappeared, only to reappear nine months later (somatic complaints, depression). After the transsphenoidal intervention the patient's psychotic symptoms had resolved and his mood had greatly improved. He started psychotropic medications (aripiprazole--20 mg in the morning and mirtazapine--30 mg at night) that was maintained till present day, with psychiatric follow-up.

CONCLUSION

In this case, as well as in literature, successful treatment of the physical signs of Cushing's syndrome, with lowering of the plasma cortisol, results in amelioration of the psychological abnormalities. These cases highlight the importance of the consideration of Cushing's syndrome as a differential diagnosis when ruling out medical causes in patients with either new or persistent mental disturbance. The physical and biochemical features associated with Cushing's syndrome can be varied and subtle at times. Early recognition and timely institution of appropriate management can minimise significant morbidity and mortality, and this is, actually, the final goal of the treatment.

ACKNOWLEDGMENTS AND DISCLOSURE

The authors declare that they have no potential conflicts of interest to disclose.

REFERENCES

(1.) Paykel, E. S., Myers, J. K., Dienelt, M. N. et al., Life events and depression, Arch Gen Psychiatry, 1969; 21:753-760

(2.) Starr, A. M., Personality changes in Cushings syndrome, J Clin Endocrinol Metab, 1952; 12:502-5

(3.) Trethowan, W. H., Cobb, S., Neuropsychiatric aspects of Cushings syndrome, Arch Neurol Psychiat, 1952; 67:283-309

(4.) Soffer, L. J., Lannaccone, A., Gabrilove, J. L., Cushings syndrome--a study of 50 patients, Am J Med, 1961; 30:129-46

(5.) Soffer, L. J., Lannaccone, A., Gabrilove, J. L., The Human Adrenal Gland, London, Henry Kimpton, 1961: 455-7, 482-3

(6.) Ross, E. J., Marshall-Jones, P., Friedman, N., Cushings syndrome: diagnostic criteria, QJ Med, 1966; 138:149-92 O Psychiatric symptoms as a clinical presentation of Cushing's disease. Case report 77

(7.) Jeffcoate, W. J., Silverstone, J. T., Edwards, C. R. W. et al., Psychiatric manifestations of Cushings syndrome: response to lowering of plasma cortisol,, QJ Med, 1979; 191:465-72

(8.) Cohen, S. I., Cushing's syndrome: A psychiatric study of 29 patients, Br J Psychiat, 1980; 136:120-4

(9.) Starkman, M. N., Schteingart, D. E., Neuropsychiatric manifestations of patients with Cushings syndrome. Relationship to cortisol and adrenocorticotrophic levels, Arch Int Med, 1981 a; 141:215-19

(10.) Haskett, R. F., Diagnostic Categorisation of psychiatric disturbance in Cushings syndrome, Am J Psychiat, 1985; 142:911-16

(11.) Starkman, M. N., Schteingart, D. E., Schort, M. A., Depressed mood and other psychiatric manifestations of Cushings syndrome: relationship to hormone levels, Psychosom Med, 1981 b; 43:3-18

(12.) Loosen, P. T., Chambliss, B., DeBold, C. R. et al., Psychiatricphenomenology in Cushings disease, Pharmacopsychiatry, 1992; 25:192-8

(13.) Hirsh, D., Orr, G., Kantarovich, V. et al., Cushing's syndrome presenting as a schizophrenia-like psychotic state, Isr J Psychiatry Relat Sci., 2000; 12:46-50

(14.) Tang, A., O'Sullivan, A., Diamond, T. et al, Psychiatric symptoms as a clinical presentation of Cushings syndrome, Ann Gen Psychiatry, 2013; 12:23

Alexandru Florescu--M. D., Ph. D. Student, Department of Endocrinology, "Sf. Spiridon" Hospital; "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania

Corina Galesanu--M. D., Ph. D., Professor, Department of Endocrinology, "Sf. Spiridon" Hospital; "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania

Didona Ungureanu--M. D., Ph. D., Associate Professor, Department of Biochemistry, "Sf. Spiridon" Hospital; "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania

Dan Niculescu--M. D., Ph. D., Professor, Department of Surgery, "Sf. Spiridon" Hospital; "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania

Liliana Moisii--M. D., Ph. D., Professor, Department of Radiology, "Sf Spiridon" Hospital; "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania

Cesara Botesatu--M. D., Ph. D., "Socola" Clinical Psychiatric Hospital, Iasi, Romania

Correspondence:

ALEXANDRU FLORESCU

Str. Ion Creanga no. 106, bloc Cl, et. 1, ap. 9, Iasi, Romania

Tel.: +40 747 087 000

E-mail: alex24_florescu@yahoo.com

Date of Submission: July, 09, 2014/ Acceptance: September, 03, 2014
Table I. Summary of all the medical procedures this patient underwent,
as well as his biochemical values of ACTH, plasmatic cortisol and
urinary free cortisol inserare

Date         ACTH      Plasmatic         UFC          Abdominal
             (N <       cortisol       (9-180            CT
           46 pg/ml)    (50-230       ug/24 h)
                         ng/ml)

                                                    Left adrenal
XII.2005               155 ng/ml     350 ug/24 h       adenoma
                                                      (0.5 cm)

I.2006     10 pg/ml                  300 ug/24 h

II.2006

III.2006                             109 ug/24 h

IV.2006                              51 ug/24 h       Glandular
                                                    tissue (1 cm)
                                                     on the left
                                                    adrenal locus

V.2006                               430 ug/24 h

VII.2006               180 ng/ml     660 ug/24 h

III.2007               513 ng/ml    1302. ug/24 h    Abdominal-
                                                       normal
                                                       Thorax-
                                                       normal

V.2008     302 pg/ml   487 ng/ml     255 ug/24 h

VI.2009                             1545 ug/24 h

VII.2012   123 pg/ml    19 ng/ml     462 ug/24 h

VII.2013   172 pg/ml    28 ng/ml    2108 ug/24 h

I.2014     216 pg/ml   13.5 ng/ml

Date         Cerebral            Surgery          Psychiatric
               MRI               (A. P.            symptoms
                              examination)

                           Left adrenalectomy      Depressed
XII.2005                   (difuse and nodular       mood,
                              hyperplasia)          anxiety

I.2006

II.2006                    Right adrenalectomy
                          (difuse hyperplasia)

III.2006

IV.2006

V.2006                                               Sleep
                                                   disorder

VII.2006    Pituitary      Surgical resection        Sleep
            fossa with    (for the left adrenal    disorder,
            homogenous      remaining tissue)      depressed
             content                                 mood
           (10/6/15 mm)

III.2007                                           Depressed
                                                     mood,
                                                    somatic
                                                  complaints

V.2008      Pituitary        Transsphenoidal       Anxiety,
            fossa with          resection         depression
            homogenous
             content

VI.2009     Pituitary        Transsphenoidal
              tumour      resection (acidophil
             (8/6 mm)      pituitary adenoma)

VII.2012

VII.2013

I.2014        normal


INTRODUCERE

Sindromul Cushing include o varietate de semne si simptome care sunt determinate de expune rea organismului pe termen lung la excesul de hormoni glucocorticoizi. Tipul exogen, cauzat de tratamentul cu glucocorticoizi al pacientilor cu afectiuni imunologice, hematologice si on cologice, este frecvent intalnit in practica medicala. Cel de tip endogen, determinat de hipersecretia de cortizol a glandei suprarenale, este totusi rar. Incidenta sindromului Cushing endogen este de aproximativ 2-3:1 000 000 locuitori pe an. Poate fi cauzat de hipersecretia de ACTH de catre un adenom hipofizar, de o tumora cu alta localizare sau de catre o sursa ACTH -independenta, cu precadere, tumora adrenala primara benigna sau maligna.

Pacientul cu sindrom Cushing tipic este usor de recunoscut din cauza aspectului clinic caracteristic: facies in luna plina, pletora, echimoze produse la traume minore, obezitate de tip central, atrofie musculara. In majoritatea cazurilor, este diagnosticat cu hipertensiune arteriala, diabet zaharat, osteoporoza, prezinta risc crescut de infectie, alaturi de variate dezechilibre fiziologice si psihiatrice. Este cunoscut faptul ca mortalitatea in sindromul Cushing netratat este crescuta. Cele mai frecvente cauze de deces sunt sepsisul, afectiunile cardiovasculare si cerebrovasculare, precum si suicidul. Una dintre cele mai mari provocari este aceea ca, in ciuda faptului ca tratamentul initial a avut succes, multi pacienti vor suferi recaderi pe termen lung, incluzand complicatiile osteoporozei, ale hipertensiunii arteriale, ale obezitatii, precum si persistenta tulburarilor psihiatrice (depresie, tulburari de dispozitie, perturbari ale somnului, anomalii cognitive, anxietate, hipomanie, confuzie).

Diagnosticul de certitudine al sindromului Cushing necesita experienta, rigurozitate in testare, analize de laborator adecvate si aplicarea protocoalelor.

PREZENTAREA CAZULUI

Motivele internarii: In decembrie 2005, un pacient in varsta de 32 de ani, de sex masculin, se adreseaza departamentului de endocrinologie pentru tensiune arteriala oscilanta, obezitate de tip central cu facies in luna plina si vergeturi abdominale. Acesta asocia, de asemenea, depresie cu tendinte psihotice (stare depresiva, anxietate si afectare somatica).

Examenul clinic a evidentiat obezitate, piele subtire ce prezenta numeroase echimoze produse la traumatisme minore, pletora faciala, striuri abdominale violacei (1 cm latime) si atrofie musculara. Indexul de masa corporala era de 32 kg/[m.sup.2], frecventa cardiaca de 90/minut, ritmic, tensiunea arteriala de 145/80 mmHg.

Examene de laborator: Biochimia sangvina a relevat valori ale hemoglobinei de 16 mg/dl, trigliceride-180 mg/ dl, un nivel normal al cortizolului plasmatic si o valoare crescuta a cortizolului liber urinar (350 mg/24 ore).

Alte examene: Radiografia de craniu profil nu a evidentiat modificari patologice, in timp ce CT-ul abdominal a indicat prezenta unei formatiuni tumorale de 5 mm situata pe glanda suprarenala stanga. Pacientul a fost dirijat catre departamentul de chirurgie unde s-a si practicat adrenalectomie stanga (rezultatul AP-hiperplazie nodulara si difuza).

In aceasta perioada, pacientul a suferit trei interventii chirurgicale pe glandele suprarenale si doua rezectii transsfenoidale, tulburarile psihiatrice variind in functie de valorile cortizolului (atat timp cat valorile se incadrau in limitele normalului, nu prezenta simptome, acestea reaparand atunci cand valorile cortizolului cresteau).

In tabelul de mai jos, am rezumat procedurile medicale efectuate pacientului, precum si valorile ACTH-ului, ale cortizolului plasmatic si cortizolului liber urinar (Tabelul I).

DISCUTII

Sindromul Cushing se poate manifesta printr-o varietate larga de simptome, fiind mai putin cunoscut totusi faptul ca simptomele psihiatrice pot face parte din tabloul clinic. In cadrul investigarii cauzei organice a unei afectiuni psihiatrice, sindromul Cushing trebuie luat in considerare, in special atunci cand sunt prezente acuze, precum hirsutismul sau hipertensiunea arteriala. A existat permanent interes privind relatia dintre evenimentele din cadrul vietii si afectiunile fizice si psihice (1). Nu a fost intotdeauna usoara stabilirea unei relatii de cauzalitate intre cele trei variabile (evenimentele vietii, afectiunile fizice si afectiunile psihice), oricare dintre acestea putandu-le influenta pe celelalte doua. Prin urmare, in momentul diagnosticului si tratamentului sindromului Cushing, natura si semnificatia unui eveniment petrecut anterior poate sa nu fie interpretat corect. Estimarile frecventei si severitatii afectiunilor psihiatrice au variat mult in diferitele studii apa rute pana in prezent. Starr a observat tulburari de personalitate la 53 de pacienti cu sindrom Cushing studiati--21 fara tulburari sau cu tulburari minime, 19 pacienti cu tulburari severe sau moderat severe si 13 pacienti cu tulburari foarte severe (2). Trethowan si Cobb au remarcat, intr-un lot de 25 de pacienti selectati aleatoriu, o "galaxie de simptome psihiatrice", dar "nicio afectiune psihiatrica clar definita" (3). Soffer si colaboratorii au observat o anumita afectare psihiatrica la 40% dintre cei 50 de pacienti cu sindrom Cushing (4); acesti autori au revazut literatura de specialitate si au descoperit simptome psihiatrice la 46% dintre pacientii cu sindrom Cushing (5). Ross si colaboratorii au notat "dificultati psihologice" la 40% dintre cei 50 de pacienti (6).

Jeffcoate a raportat anomalii psihiatrice la 65% din 38 de pacienti cu sindrom Cushing (7). Cohen, in anul 1980, a descoperit "tulburari afective distincte" la 86% dintre cei 29 de pacienti cu sindrom Cushing (8). Starkman a indicat o simpto matologie variata la 35 de pacienti cu sindrom Cushing, evaluand "dizabilitatea psihiatrica" ca fiind usoara in 34% dintre cazuri, moderata pentru 26%, severa la 29% si foarte severa in 11% dintre cazuri (9). Hasket a raportat faptul ca 83% dintre cei 30 de pacienti cu sindrom Cushing au prezentat criterii clare de diagnostic a afectiunilor psihiatrice, incluzand depresie, manie si hipomanie (10). Starkman a remarcat prezenta anxietatii la 66% dintre 35 de pacienti (11), iar Loosen, tulburarea anxioasa generalizata la 79% dintr-un lot de 20 de pacienti (12). Sunt raportate cazuri in care sindromul Cushing a debutat printr-o stare psihotica schizofrenie-like (13) sau sindrom depresiv cu tendinte psihotice (halucinatii auditive si iluzii nihilistice) (14).

In cazul prezentat, pacientul a fost admis in spital cu depresie majora si tendinte psihotice, avand stare depresiva, anxietate, acuze somatice. Declinul mental a fost progresiv in ultimele doua luni, neexistand antecedente personale patologice psihiatrice semnificative. Dupa primele sase saptamani post-chirurgie (adrenalectomie stanga), psihoza s-a remis, pacientul fiind stabil pana in anul 2006, cand simptomele au reaparut (tulburari ale somnului, depresie). A fost efectuata o alta interventie chirurgicala (pe tesutul suprarenalian restant); dupa aproximativ 30 de zile, simptomele s-au remis, dar au reaparut noua luni mai tarziu (acuze somatice, depresie). Dupa interventia transsfenoidala, tulburarile psihotice au disparut complet, iar starea psihica s-a imbunatatit progresiv. S-a initiat terapie cu medicatie psihotropa (aripiprazole -20 mg dimineata si mirtazapine--30 mg seara), tratament mentinut si in prezent, cu evaluare psihiatrica periodica si evolutie favorabila.

CONCLUZII

In acest caz, ca si in cele descrise in literatura de specialitate, scaderea valorii cortizolului plasmatic impreuna cu tratamentul eficient al simptomatologiei generale duc la ameliorarea tulburarilor psihiatrice. Acest caz subliniaza importanta includerii sindromului Cushing in diagnosticul diferential al tulburarilor psihice nou instalate sau persistente. Simptomatologia si parametrii biochimici ai acestui sindrom pot varia in timp si se pot estompa. Recunoasterea precoce si initierea din timp a terapiei adecvate pot scadea morbiditatea si mortalitatea, acesta fiind scopul final al tratamentului.

MULTUMIRI SI DEVOALARI

Autorii nu declara existenta vreunui conflict de interese legat de acest articol.

BIBILIOGRAFIE

(1.) Paykel, E. S., Myers, J. K., Dienelt, M. N. et al., Life events and depression, Arch Gen Psychiatry, 1969; 21:753-760

(2.) Starr, A. M., Personality changes in Cushings syndrome, J Clin Endocrinol Metab, 1952; 12:502-5

(3.) Trethowan, W. H., Cobb, S., Neuropsychiatric aspects of Cushings syndrome, Arch Neurol Psychiat, 1952; 67:283-309

(4.) Soffer, L. J., Lannaccone, A., Gabrilove, J. L., Cushings syndrome--a study of 50 patients, Am J Med, 1961; 30:129-46

(5.) Soffer, L. J., Lannaccone, A., Gabrilove, J. L., The Human Adrenal Gland, London, Henry Kimpton, 1961: 455-7, 482-3

(6.) Ross, E. J., Marshall-Jones, P., Friedman, N., Cushings syndrome: diagnostic criteria, QJMed, 1966; 138:149-92

(7.) Jeffcoate, W. J., Silverstone, J. T., Edwards, C. R. W. et al., Psychiatric manifestations of Cushings syndrome: response to lowering of plasma cortisol,, QJ Med, 1979; 191:465-72

(8.) Cohen, S. I., Cushing's syndrome: A psychiatric study of 29 patients, Br J Psychiat, 1980; 136:120-4

(9.) Starkman, M. N., Schteingart, D. E., Neuropsychiatric manifestations of patients with Cushings syndrome. Relationship to cortisol and adrenocorticotrophic levels, Arch Int Med, 1981 a; 141:215-19

(10.) Haskett, R. F., Diagnostic Categorisation of psychiatric disturbance in Cushings syndrome, Am J Psychiat, 1985; 142:911-16

(11.) Starkman, M. N., Schteingart, D. E., Schort, M. A., Depressed mood and other psychiatric manifestations of Cushings syndrome: relationship to hormone levels, Psychosom Med, 1981 b; 43:3-18

(12.) Loosen, P. T., Chambliss, B., DeBold, C. R. et al., Psychiatricphenomenology in Cushings disease, Pharmacopsychiatry, 1992; 25:192-8

(13.) Hirsh, D., Orr, G., Kantarovich, V. et al., Cushing's syndrome presenting as a schizophrenia-like psychotic state, Isr J Psychiatry Relat Sci., 2000;12:46-50

(14.) Tang, A., O'Sullivan, A., Diamond, T. et al, Psychiatric symptoms as a clinical presentation of Cushings syndrome, Ann Gen Psychiatry, 2013; 12:23

Alexandru Florescu--M. D., Doctorand, Disciplina Endocrinologie, Universitatea de Medicina si Farmacie "Grigore T. Popa" Iasi, Romania

Corina Galesanu--M. D., Ph. D., Profesor universitar, Clinica de Endocrinologie, Spitalul "Sf. Spiridon"; Universitatea de Medicina si Farmacie "Grigore T. Popa" Iasi, Romania

Didona Ungureanu--M. D., Ph. D., Conferentiar universitar, Departamentul de Biochimie, Spitalul "Sf. Spiridon"; Universitatea de Medicina si Farmacie "Grigore T. Popa" Iasi, Romania

Dan Niculescu--M. D., Ph. D., Profesor universitar, Clinica I--Chirurgie, Spitalul "Sf. Spiridon"; Universitatea de Medicina si Farmacie "Grigore T. Popa" Iasi, Romania

Liliana Moisii--M. D., Ph. D., Profesor universitar, Clinica de Radiologie, Spitalul "Sf. Spiridon"; Universitatea de Medicina si Farmacie "Grigore T. Popa" Iasi, Romania

Cesara Botezatu--M. D., Ph. D., Spitalul Clinic de Psihiatrie "Socola" Iasi, Romania

Corespondenta:

ALEXANDRU FLORESCU

Strada Ion Creanga nr. 106, Bloc C1, etaj 1, ap. 9, Iasi, Romania

Tel.: +40 747 087 000

E-mail: alex24_florescu@yahoo.com

Trimis: 09 Iulie 2014 / Acceptat: 03 Septembrie 2014
Tabelul I. Sumarizarea procedurilor medicale efectuate pacientului,
precum si valorile ACTH-ului, ale cortizplului plasmatic si
cortizolului liber urinar

Data         ACTH       Cortizol         CLU            CT
            (N < 46    plasmatic    (9-180 ug/24H)    abdomen
            pg/ml)     (50-230
                        ng/ ml)

XII.2005               155 ng/ml     350 ug/2.4 h     Adenom
                                                        GSR
                                                     (0,5 cm)

I.2006     10 pg/ml                  300 ug/2.4 h

II.2006

III.2006                             109 ug/24 h

IV.2006                137 ng/ml      51 ug/24 h       Tesut
                                                     glandular
                                                      (1 cm)

V.2006                               430 ug/24 h

VII.2006               180 ng/ml     660 ug/24 h

III.2007               513 ng/ml     1302 ug/24 h    Abdomen -
                                                      normal
                                                     Torace -
                                                      normal

V.2008     302 pg/ml   487 ng/ml     255 ug/24 h

VI.2009                              1545 ug/24 h

VII.2012   123 pg/ml    19 ng/ml     462 ug/24 h

VII.2013   172 pg/ml    28 ng/ml     2108 ug/24 h

I.2014     216 pg/ml   13,5 ng/ml

Data           RMN           Interventie        Manifestari
            cerebral        chirurgicala        psihiatrice
                             (ex.: A.P.)

XII.2005                   Adrenalectomie       Anxietate,
                         stanga (hiperplazie     depresie
                          difuza nodulara)

I.2006

II.2006                    Adrenalectomie
                               dreapta
                            (hiperplazie
                               difuza)

III.2006

IV.2006

V.2006                                           Tulburari
                                               ale somnului

VII.2006      Loja            Rezectie           Tulburari
           hipofizara       chirurgicala       ale somnului,
           cu continut       a tesutului         depresie
           hiperfixant      suprarenalian
             (10/6/            restant
             15 mm)

III.2007                                         Depresie,
                                                 tulburari
                                                 somatice

V.2008        Loja            Rezectie          Anxietate,
           hipofizara      transsfenoidala       depresie
           cu continut
           hiperfixant

VI.2009      Tumora           Rezectie
           hipofizara      transsfenoidala
            (8/6 mm)

VII.2012

VII.2013

I.2014       normal
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Article Details
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Author:Florescu, Alexandru; Galesanu, Corina; Ungureanu, Didona; Niculescu, Dan; Moisii, Liliana; Botezatu,
Publication:Bulletin of Integrative Psychiatry
Article Type:Clinical report
Date:Sep 1, 2014
Words:3748
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