The following article is a part of conference coverage from the American Academy of PAs 2021 Conference (AAPA 2021), held virtually from May 23 to May 26, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading PAs. Check back for more from AAPA 2021
A 49-year-old man with a 10-year history of type 2 diabetes presents with progressive proximal muscle weakness and debilitating fatigue that began 1 year prior, as described in a case study presented at the American Academy of PAs 2021 Conference (AAPA 2021). The patient has a 10-year history of type 2 diabetes and past medical history of hypertension, hip fracture, idiopathic vascular calcification, deep vein thrombosis (DVT), and separate left ulnar arterial thrombosis.
His history of DVT and ulnar arterial thrombosis are thought to be secondary to factor V Leiden, which is positive in his family as is type 2 diabetes. He is a nonsmoker and denies illicit drug use. Medications include aspirin, apixaban, amlodipine, candesartan, metformin, sitagliptin, and atorvastatin.
Physical Examination and Laboratory Findings
On physical examination, he appears fatigued. He is 5’9” tall and weighs 186 lb. Vital signs and abnormal findings on physical examination are shown in Tables 1 and 2.
Table 1. Vital Signs
|Pulse, beats per minute||88|
|Respiratory rate, breaths per minute||12|
|Blood pressure, mm Hg||110/64|
Table 2. Abnormal Findings
|Mild facial plethora|
|Supraclavicular fat pads|
|Pink abdominal striae|
|Bilateral proximal muscle strength, 4/5|
|Left hand strength, 3/5|
Laboratory tests for complete blood count, metabolic panel, thyroxine (T4), and thyrotropin are normal, although he has mild neutrophilia (not a new finding). His urinalysis is normal except for presence of glucose. His glycated hemoglobin A1c (HbA1c) is 6.7%.
Secondary Causes of Diabetes
While most cases of diabetes are type 1 or type 2, other less common varieties sometimes referred to as secondary causes of diabetes may occur. Secondary diabetes may be associated with pregnancy (gestational), chronic pancreatitis, glucocorticoid use, and other endocrinopathies such as pheochromocytoma, acromegaly, and Cushing syndrome.
The patient is suspected of having Cushing syndrome and underwent endocrine evaluation (Table 3), which demonstrates high levels of 2-hour urine free cortisol, salivary cortisol, and plasma adrenocorticotropic hormone (ACTH), as well as failure to suppress morning plasma cortisol,
Table 3. Endocrine Evaluation
|24-hour urinary free cortisol||86 mcg (nl <45)|
|Salivary cortisol (at 11:00 pm)||518 ng/dL (nl < 100)|
|Low-dose overnight dexamethasone||Test reveal failure to suppress morning plasma cortisol: 19.85 mcg/dL (nl <1.8)|
|ACTH||169 pg/mL (nl <63)|
|Insulin-like growth factor-1||Normal|
|Follicle stimulation hormone||Normal|
ACTH, adrenocorticotropic hormone; Micrograms, mcg; nanometer per deciliter, ng/dL; normal laboratory finding, nl; micrograms per deciliter, mcg/dL; picograms per milliliter, pg/mL.
Diagnostic Imaging and Treatment
Magnetic resonance imaging (MRI) with gadolinium contrast of the pituitary gland demonstrates a sellar mass measuring 11 x 16 mm.
Due to the COVID-19 pandemic, surgery is delayed until 3 months after a pituitary macroadenomas diagnosis. Tumor resection by endoscopic endonasal trans-sphenoidal hypophysectomy reveals a 1.1-cm corticotroph pituitary adenoma; it stains positive for radiolabeled ACTH confirming the source of autonomous ACTH secretion.
Follow-Up After Pituitary Surgery
After surgery, his plasma cortisol fell from >20 mcg/dL to 4.2 mcg/dL. Five months post-surgery, his HbA1c decreased from 6.7% to 5.6% with weight loss of 35 lb (186 lb to 151 lb).
Concluding Case Comments
“In this case, it is unknown whether Cushing syndrome supervened in this patient with diabetes or if Cushing syndrome alone was present from the beginning,” noted study authors Jeffrey Vasiloff, MD, and Melissa Bowlby, PA-C, who are both faculty members in the Division of PA Practice, College of Health Sciences and Professions of Ohio University in Dublin, Ohio.
“While type 2 diabetes is expected to progress, it is paramount for clinicians to consider concurrent or other etiologies when atypical clinical features appear. Here, treatment of Cushing syndrome led to marked improvement in diabetes,” they concluded.
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- Bowlby M, Vasiloff J. Unusual cause of diabetes: a case study. Poster presented at: American Academy of PAs 2021 Conference; May 23-26, 2021. Poster 136.