Cushing Syndrome During Pregnancy Presenting With Neuropsychiatric Symptoms

Cushing syndrome (CS) in pregnancy is a rare condition characterized by endogenous hypercortisolism. This case is particularly noteworthy because the patient presented with psychogenic nonepileptic seizures (PNES), a neuropsychiatric manifestation that is seldom documented as a primary presentation of adrenocorticotropic hormone (ACTH)-independent CS during gestation. The objective of this report is to describe a patient with a cortisol-producing adrenal adenoma during pregnancy with the aim of highlighting the diagnostic challenges of managing rare neuropsychiatric symptoms and refractory hypertension.

A case of a 30-year-old pregnant woman diagnosed with cortisol-producing adrenal adenoma at 16 weeks of gestation, presenting with PNES and severe hypertension. Biochemical tests revealed elevated 24-hour urine free cortisol and suppressed ACTH levels, confirming ACTH-independent CS. A laparoscopic adrenalectomy was performed at 20 weeks, followed by stabilization of cortisol levels and management of hypertension. Due to nonreassuring fetal status, an emergency cesarean section was conducted at 34 weeks, resulting in a healthy infant. Postpartum follow-up showed resolution of hypertension and normalization of neuropsychiatric symptoms.

CS in pregnancy is rarely encountered due to hypercortisolism-induced infertility. The diagnosis of CS in pregnancy is often delayed by the physiological overlap of pregnancy symptoms, yet the specific presentation of PNES remains a highly atypical manifestation.

This case emphasizes the necessity for clinicians to maintain a high index of suspicion for CS in pregnancy when encountering refractory hypertension and atypical neuropsychiatric symptoms.