Hyperinsulinism and Cushing's Syndrome

A 43-year-old postman was first seen in hospital on 2 September 1962. He had been unwell for five weeks. He complained of being rather " hazy in the head " and of having " slowed-up " mentally. He felt agitated, had constant headaches, and a feeling of constriction in his chest. His speech had been slower and occasionally slurred. Owing to weariness, walking had become difficult, although he had no definite weakness or pain in his limbs. He complained of dryness of the mouth, with thirst, polyuria, and nocturia. His appetite remained good, and there was moderate constipation. Two to three weeks before consultation he gained weight rapidly, increasing from his usual weight of 11 st. 7 lb. (73 kg.) to 12 st. 71b. (79 kg.). He stated that his face appeared swollen and that sometimes his legs swelled. Acneiform spots had appeared on his trunk and face. Apart from malaria many years previously, he had always been in excellent health. He gave the appearance of being well. His skin was heavily pigmented, especially in exposed areas and about the genitalia. His skin was thin and contained several small bruises. On the trunk many acne pustules were present. There was mild generalized stomatitis and his tongue was dry. The liver edge was just palpable. Moderate oedema of both legs was present, extending up to the knee. There were no other physical abnormalities. The bloodpressure was 140/70 mm. Hg. Urinalysis was normal. X-ray examination of the skull, chest, and pelvis, and an intravenous pyelogram revealed no abnormalities save generalized osteoporosis. A diagnosis was made of atypical Cushing's syndrome and investigations were undertaken to confirm and determine its aetiology.