Occasionally a patient with Munchausen's syndrome may present with Cushing's syndrome or claims of Cushing's syndrome. Diagnosis may be difficult unless a significant discrepancy can be identified.


Mechanism of fraud:

(1) ingestion or injection of synthetic steroids

(2) tampering with urine samples


Clinical features:

(1) history of anxiety, depression or drug abuse

(2) close contact with health care (self, friend or relative)

(3) evidence of self-injection

(4) history of factitious disease


Imaging studies:

(1) adrenal glands on imaging studies may be of normal size, small or atrophic

(2) pituitary imaging studies may be normal or show incidental microadenomas


Laboratory findings:

(1) striking variability in urine free cortisol

(2) striking variability in urine 17-hydroxysteroid (17-OHCS)

(3) discrepancy between serum and urine steroid levels (serum normal, urine very high)

(4) discrepancy between free cortisol and free corticosterone concentrations (in excess production both should be increased; in factitious disease cortisol is elevated and corticosterone is normal; in cortisol self-medication corticosterone is decreased)

(5) normal serum ACTH levels

(6) presence of synthetic glucocorticoids on HPLC analysis of urine


Differential diagnosis:

(1) accidental contamination of urine by vaginal cream containing cortisol

(2) periodic Cushing's syndrome


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