Question

Sherry is a 30-year-old woman who presents with complaints of a yeast infection that keeps coming back. She also reports increased thirst and urinary frequency. She has self-treated her yeast infection and says that those symptoms have cleared at the present time. Over the last few years, she has gained about 30 pounds, despite having tried many different diets. Her only other medical problem is PCOS, for which she takes Metformin ER 500 mg (2] tablets twice per day. FH is unknown because she was adopted. She has had one pregnancy and one live birth her son was born healthy but weighed 9 pounds and 10 ounces. On exam her BP is 138/86 her pulse is 72 and her respiratory rate is 16. She is 65 inches tall and weights 215 pounds. Her exam reveals darkened skin that appears thickened on the back of her neck. Her pelvic exam is unremarkable. The urine analysis if negative for bacteria, but + for glucose. Her postprandial BS here in the office today is 289 mg/dL. BSA

what should she be prescribed?

Answer 1

Features are:

Body weight 215 pound and height 65 inches - obese

Weight gain despite dietary modification - alone not effective in regulation of weight

PCOS and metformin 500 mg twice pre day

Darkened and thickened skin on the back of her neck

Repeated yeast infections

Thirst and urinary frequency

Glyscouria +

Post prandial blood sugar 289 mg / dl

Vitals in normal range

Patients presentation of symptoms and assessment findings are indicating towards possibility of three conditions Diabetes mellitus and polycystic ovarian syndrome.

As the patient is already diagnosed with PCOS and on metformin. Metformin is an antihyperglycemic agent, which improves glucose tolerance in patients with type 2 diabetes, lowering both basal and postprandial plasma. Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization.

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As glucose Insulin resistance is commonly seen in a woman with PCOS and play an important role in the pathophysiology of PCOS. So antidiabetic drug metformin (although usually prescribed for treatment of type 2 diabetes) is commonly used in women with PCOS, particularly in those who are overweight or obese. It works by improving insulin sensitivity on receptor sites which in turn decreases insulin resistance and lowers blood glucose level.

Despite being on metformin patient is not having blood sugar under control as evidenced by Postprandial blood sugar 289 mg/dl and the presence of sugar in the urine. However it seems that the patient is having betterment in PCOS symptoms as there is no complaint regarding that.

It suggests that the cause of hyperglycemia may have other causes and need to be diagnosed and treated. There are two possibilities for Cushing's syndrome/disease and Type 2 diabetes mellitus.

Patients finding of darkened and thickened skin on the back of her neck( acanthosis nigricans), second is the patient is having hyperglycemia which can be secondary to glucocorticoid excess occurring in Cushing syndrome. Hence it is essential to rule out Cushing syndrome.

Cushing’s syndrome can be difficult to diagnose as it mimics many other conditions and may be mistaken for other conditions that have many of the same signs, such as polycystic ovary syndrome or metabolic syndrome. To rule out diabetes mellitus and for differential diagnosis – the following tests can be conducted-

· Oral glucose tolerance test and evaluation according to criteria laid by the American Diabetic Association or by WHO.

· Fasting and 2-hour postprandial blood glucose

· Cortisol level in urine, saliva, or blood tests to diagnose Cushing’s syndrome

· 24-hour urinary free cortisol test

· Dexamethasone suppression test (DST): in this test measures blood level of cortisol after administering a dose of dexamethasone, a type of glucocorticoid. Normally, cortisol levels in the blood drop after taking dexamethasone. Cortisol levels if does not decrease, suggest Cushing’s syndrome.

· Next step is to measure ACTH levels in the blood. If ACTH levels are low, the cause is probably an adrenal tumor. People with adrenal tumors don’t need further blood tests.

· CRH stimulation test has been used to identify the source of excess ACTH in ACTH-dependent Cushing syndrome. Pituitary tumors tend to be sensitive to CRH stimulation while ectopic tumors ( those ACTH secreting tumors in lungs) do not usually respond. Patients with hypercortisolism due to oversecretion of ACTH by the pituitary (Cushing disease) generally respond to CRH with a >20% rise in cortisol at 1 minute and a >35% increase in ACTH at 5 minute interval after injection.In most cases, patients with primary adrenal hypercortisolism or ectopic ACTH syndrome do not respond to CRH.

· Imaging tests. Imaging tests show the size and shape of the pituitary and adrenal glands and look for tumors. If blood tests show that the tumor is ectopic, imaging tests can help locate the tumor. The most common imaging tests are the computerized tomography (CT) scan NIH external link and magnetic resonance imaging (MRI)

Meanwhile definitive diagnosis is arrived Insulin injection is to be addede to control hyperglycemia which will take care of blood glucose and urinary passage of glucose will be reduced.

Repeated yeast infections are common in patients having hyperclycemia. So once blood sugar is under control it will settle down, if not anti fungal agents may be added.