Endo Case Challenge: A 36-Year-Old Has Cramping, Lung Issues and Can’t Lose Weight

Romesh Khardori, MD, PhD


March 31, 2022


The endocrinologist obtained an additional history of verified "stretch marks" as striae often seen in Cushing syndrome. He also noticed prominent supraclavicular fat pads. A combination of hypercortisolemia, elevated ACTH levels, hypokalemia, fatigue, and persistent left lower lung atelectasis persuaded the endocrinologist to strongly consider ectopic ACTH syndrome. The facial flushing and lack of a tobacco smoking history favored an endobronchial carcinoid, as opposed to small cell lung cancer. Bronchoscopy was performed, and histoimmunopathology confirmed the diagnosis of an ACTH-secreting carcinoid. An example of similar immunohistopathology is shown in Figure 2.

Figure 2.

Although other causes of type 2 diabetes mellitus and hypertension are possible, this combination of findings with unprovoked hypokalemia strongly suggests Cushing syndrome.

Dietary indiscretion and consumption of excess calories can cause weight gain; however, in a patient with worsening glycemic control, the presence of glycosuria generally negates excessive weight gain. Hypothyroidism makes it difficult to lose weight and may lead to increase in blood pressure or worsening of hypertension. However, neither causes unprovoked hypokalemia.

Stress hyperphagia is often noticed in people operating under pressure. People report frequent snacking, and stress leads to worsening of glycemia. Catecholamine surge associated with physical injury is accompanied by catecholamine-mediated hypokalemia. Hypokalemia is not persistent and abates when the stress level recedes. Weight gain is not a feature of catecholamine-driven hypertension or hypokalemia (eg, pheochromocytoma).


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