Lesson of the month 2: Cauda equina in Cushing's ...
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Lesson of the month 2: Cauda equina in Cushing's ...
We present the case of a 34-year old woman who initially presented with obesity and back pain. She was eventually diagnosed with Cushing's syndrome ...
LESSON OF THE MONTH
Clinical Medicine 2016 Vol 16, No 1: 88–90
Lesson of the month 2: Cauda equina in Cushing’s syndrome
ABSTRACT
Authors: Douglas Maslin, A Ioannis Gounaris,B Kenrick NgC and Pippa CorrieD
We present the case of a 34-year old woman who initially presented with obesity and back pain. She was eventually diagnosed with Cushing's syndrome secondary to an adrenocortical carcinoma that had metastasised to her spine, causing cauda equina compression. The delays in reaching the correct diagnosis caused significant morbidity and exemplify the pitfalls of premature closing, a common cognitive error in diagnostic reasoning. KEYWORDS: Cushing’s syndrome, adrenocortical carcinoma, cauda equina, back pain, premature closing
Case report A 34-year-old woman presented to the emergency department with severe central lower back pain and paraplegia. The back pain had started after her bed collapsed two months previously and had since been steadily worsening. She had recently visited her general practitioner who diagnosed mechanical back pain secondary to obesity and prescribed simple analgesics. She had visited a chiropractor four days previously and also attended the emergency department at another hospital two days before. On that occasion, examination identified tender lower thoracic and lumbar vertebrae and paraspinal muscles, but a full neurological examination was not carried out (‘pain limited examination’). The diagnosis of musculoskeletal back pain secondary to morbid obesity was made and the patient discharged with a plan for outpatient lumbar radiographs. On presentation to our institution, she had been unable to walk for six days. The patient reported significant weight gain over the preceding 18 months (from clothing size 16 to 28) and now weighed 172 kg. She reported low mood and amenorrhoea over the last 12 months. She had been prescribed sertraline for depression and furosemide for lower limb oedema. Blood tests performed a few months before had shown low folliclestimulating hormone (
