Abstract: The Preeclampsia Mimic: A Case Report of Cyclic Cushing's Disease Unmasked in the Postpartum Period.
Cushing's disease in pregnancy is rare and frequently underrecognized due to clinical overlap with physiologic gestational changes and hypertensive disorders of pregnancy, particularly preeclampsia. Delayed diagnosis may result in prolonged maternal morbidity and inappropriate management.
A 30-year-old gravida 2, para 1 woman delivered at 37 weeks' gestation via induced vaginal delivery for preeclampsia without severe features. Her immediate postpartum course was unremarkable. At 12 weeks postpartum, she developed persistent proteinuria with associated hypercalciuria and hyperuricosuria despite preserved renal function. Over the following weeks, she developed hypokalemia, leukocytosis, and progressive cushingoid features including facial rounding, dorsocervical fat pad, central obesity, proximal muscle weakness, hypertension, easy bruising, hirsutism, and frequent falls. Endocrine evaluation revealed markedly elevated serum and urinary cortisol levels with concomitant hyperandrogenism. Magnetic resonance imaging demonstrated a 9-mm pituitary adenoma with evidence of hemorrhage. She was diagnosed with cyclic Cushing's disease with intermittent adrenal insufficiency and initiated on glucocorticoid replacement therapy. Transsphenoidal resection of the adenoma was performed at 26 weeks postpartum, resulting in improvement in blood pressure and clinical symptoms. At one year postpartum, she remained clinically stable on glucocorticoid replacement therapy.
This case highlights the importance of maintaining a broad differential diagnosis in patients with hypertensive disorders of pregnancy. Persistent hypertension, proteinuria, and metabolic abnormalities should prompt evaluation for underlying endocrinopathies such as Cushing's disease. Early recognition and multidisciplinary management are critical to optimizing maternal outcomes and avoiding misattribution of symptoms to preeclampsia alone. Emerging biomarkers, including sFlt-1/PlGF ratios, may further aid in distinguishing preeclampsia from alternative pathologic processes.
A 30-year-old gravida 2, para 1 woman delivered at 37 weeks' gestation via induced vaginal delivery for preeclampsia without severe features. Her immediate postpartum course was unremarkable. At 12 weeks postpartum, she developed persistent proteinuria with associated hypercalciuria and hyperuricosuria despite preserved renal function. Over the following weeks, she developed hypokalemia, leukocytosis, and progressive cushingoid features including facial rounding, dorsocervical fat pad, central obesity, proximal muscle weakness, hypertension, easy bruising, hirsutism, and frequent falls. Endocrine evaluation revealed markedly elevated serum and urinary cortisol levels with concomitant hyperandrogenism. Magnetic resonance imaging demonstrated a 9-mm pituitary adenoma with evidence of hemorrhage. She was diagnosed with cyclic Cushing's disease with intermittent adrenal insufficiency and initiated on glucocorticoid replacement therapy. Transsphenoidal resection of the adenoma was performed at 26 weeks postpartum, resulting in improvement in blood pressure and clinical symptoms. At one year postpartum, she remained clinically stable on glucocorticoid replacement therapy.
This case highlights the importance of maintaining a broad differential diagnosis in patients with hypertensive disorders of pregnancy. Persistent hypertension, proteinuria, and metabolic abnormalities should prompt evaluation for underlying endocrinopathies such as Cushing's disease. Early recognition and multidisciplinary management are critical to optimizing maternal outcomes and avoiding misattribution of symptoms to preeclampsia alone. Emerging biomarkers, including sFlt-1/PlGF ratios, may further aid in distinguishing preeclampsia from alternative pathologic processes.