Woman in her thirties presented to the emergency room with a two-week history of worsening headache and diplopia. For eight years she had suffered from progressive weight gain, diabetes and hypertension that didn't improve with lifestyle modification. A lumbar puncture demonstrated increased intracranial pressure and MRI a pituitary adenoma. Physical examination was consistent with Cushing's syndrome and endocrine workup confirmed Cushing's disease. Treatment was complex, including unsuccessful pituitary surgery and gamma knife radiosurgery, and eventually bilateral adrenalectomy with subsequent development of Nelsons syndrome. This case illustrates the diagnostic delay that many patients with CD suffer from.

Key words: Cushing's syndrome, Cushing's disease, cortisol, Nelsons syndrome, pituitary adenoma

Correspondence: Aron Hjalti Björnsson, aronhjalti@gmail.com

1) Dept of Medicine, The National University Hospital of Iceland 2) Faculty of Medicine, School of Health Sciences, University of Iceland 3) Primary Health Care of the Capital Area, Iceland 4) Dept of Neurosurgery, The National University of Iceland 5) Dept of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden 6) Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden, Table I: Signs and clinical features of Cushing‘s syndrome Table II: Timeline of major events, Image 1: A magnetic resonance imaging of the patient‘s brain performed during her admission at the Department of Neurology. A sagittal T1-weighted imaging showing an irregular lesion (arrow) in the pituitary that is consistent with pituitary apoplexy., Image 2: A magnetic resonance image performed 5 months later than Image 1. The lesion has disappeared (arrow) and there is no apparent pathology within the pituitary., Image 3A: Descriptive habitus for Cushing’s syndrome. Central obesity with striae, thin arms and legs, moon face, facial plethora and supraclavicular fat pads., Image 3B: Buffalo hump with fat disposition on the upper back. Moon face and plethora., Image 3C: Central fat disposition with stria without characteristic violaceous appearance.