ESPE Abstracts

Anorexia nervosa (AN) manifests in the restriction of energy intake relative to energy output. Atypical AN includes those who meet the criteria for AN but are not underweight. Hypothalamic amenorrhea can be a presenting symptom in AN, and the return of menses is part of recovery. It can take more than a year for menses to return after weight restoration and nutritional rehabilitation. Hypercortisolemia is common in AN, but usually does not cause cushingoid symptoms We describe a 15 year old female with rapid 12 kg weight gain and anxiety at the age of 12 years that was attributed to environmental changes in her life (from 52 kg to 64 kg). A year later, she lost 20 kg in 8 months (44 kg) and was diagnosed with atypical restrictive AN and anxiety. She was treated in a multidisciplinary adolescent clinic with psychotherapy, dietitian counseling and sertraline up to 200 mg. Primary amenorrhea was attributed to her malnutrition. At the age of 15, after successful treatment at the adolescent clinic, her weight was stable at 53 kg. Despite behavioral recovery she did not commence menses. Since her breast tanner staging did not fit the amenorrhea, a combined ACTH and LHRH test was done. LH rose from 1.4 IU/l to 26.7 and FSH from 4.1 IU/l to 15.2, cortisol rose from 615 nmol/l to 1630. Free urinary cortisol (235 mg /h), 1 mg dexamethasone suppression test (1897 nmol/l), salivary midnight cortisol (0.91 mg/ 100ml), 8 mg dexamethasone suppression test (780 nmol/l) and combined low dose dexamethasone suppression test with CRH all showed high levels of cortisol (1268 nmol/l) and ACTH (35 pmol/l). MRI showed a small hypodense nodule in the left side of the pituitary, slightly intense T2 signal. The stalk was in place. A 4-5 mm microadenoma was suspected. She underwent a trans-sphenoidal resection of the tumor successfully. Pathology showed a sparsely granulated corticotroph adenoma. Two months after resection she commenced menstruating and has regular periods. Her weight is stable and eating habits are within the norm. Cushing’s disease (CD) clinically overlaps with AN and anxiety. CD in children can manifest as growth failure, irregular menses, and depression. CD is difficult to diagnose, diagnosing CD in AN patient is even more challenging. It is important to consider other potential etiologies for amenorrhea rather than malnutrition alone, such as CD.