Authors: Venu Julapalli, MD; Mehnaz Shafi, MD; Jim Schwartz, MDSeries Editor: Richard Goodgame


April 19, 2004

Case Presentation

A 42-year-old man with a 15-year history of heartburn presented to clinic.* His symptoms became more frequent and severe approximately 6 weeks before this presentation, and he began taking proton-pump inhibitors (PPIs). About the same time, the patient observed the following changes in his physical appearance: 20-lb weight gain; development of a fat face and abdomen; increased facial hair; and acne on the face, neck, chest, and back. His primary care physician noted new-onset hypertension and began treatment. Four days ago, he developed a constant, dull epigastric pain and began passing melenic stools multiple times per day. There was no nausea or diarrhea.

His medical history was significant for cholecystectomy and bilateral inguinal hernia repair. His current medications included diltiazem, valsartan, furosemide, potassium, and lansoprazole.

There was no history of alcohol abuse, tobacco use, or any other substance abuse. His mother had diabetes and hypertension. His father had heart disease and hypertension. There was no family history of peptic ulcer disease or other endocrine diseases.

Physical examination showed normal vital signs; his height was 66 in and his weight was 160 lb (up from 140 lb). The patient was cushingoid (Figure 1) and had generalized acne in the upper body (Figure 2). There were purple striae at the hips bilaterally and ecchymoses on both arms.

Routine laboratory studies revealed the following values: hemoglobin, 13 g/dL; white blood cell count, 16 x 103 cells/mm3; platelets, 206 x 103/mm3; mean corpuscular volume, 91 fL; sodium, 147 mEq/L; potassium, 2.3 mEq/L; chloride, 97 mEq/L; HCO2, 38 mEq/L; glucose, 127 mg/dL; blood urea nitrogen, 15 mg/dL; creatinine, 0.8 mg/dL; calcium, 9.5 mg/dL; phosphate, 2.9 mg/dL; total protein, 6 g/dL; albumin, 4 g/dL; total bilirubin, 0.4 g/dL; direct bilirubin, 0.3 g/dL; alkaline phosphatase, 93 U/L; alanine aminotransferase, 59 U/L; aspartate aminotransferase, 34 U/L; international normalized ratio, 1.0; and urine glucose, 3+.

Prior endocrine evaluation had revealed the following: serum cortisol, 111 mcg/dL (normal range, 5-25 mcg/dL); 24-hour urinary free cortisol, 4648 mcg/day (normal range, < 45); and serum adrenocorticotropic hormone (ACTH), 603 pg/mL (normal range, 6-58).

An esophagogastroduodenoscopy was performed; results showed an ulcer in the second part of the duodenum (Figure 3). In addition, the endoscopist was impressed with the abundant secretions present in the stomach (Figure 4) and the thick gastric folds (Figure 5). The patient had been NPO but had been given intravenous pantoprazole, 40 mg twice daily. The pH of the aspirated gastric contents was 2.5. Results of biopsy of the thick gastric folds showed increased numbers of gastric glands and abundant parietal cells (Figure 6).

*Please note that some details in this case have been changed to protect the patient's identity.


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