Case presentation

A 29-year-old man was referred by his primary care physician for hypertension resistant to antihypertensive drugs. For 1 year he had been suffering from bradypsychia, dizziness, asthenia, adynamia, muscle weakness and weight gain. On physical examination, he was observed to have central obesity, buffalo hump, facial fullness, skin thinning and abdominal skin stretch marks up to 1.5 cm in diameter, with a purplish appearance (Figure 1). Cushing’s syndrome was confirmed by a 24-hour urine free cortisol test. The abdominal CT showed a 29 mm lesion in the right adrenal gland with 35 HU in the simple phase, 72% washout in the arterial phase. He underwent laparoscopic adrenalectomy, without complications.

Figure 1: Striae rubrae in a patient with cushing’s syndrome.

Discussion

Striae distensae, also known as stretch marks, are common skin lesions. They appear early as erythematous raised linear lesions, called striae rubrae [1]. Striae rubrae or red striae are found in different circumstances like pregnancy, weight gain or Cushing’s syndrome [1,2]. Cushing’s syndrome is caused by excessive tissue exposure to glucocorticoids (endogenous or exogenous). The clinical diagnosis requires the recognition of an array of clinical features, and stretch marks are among the most discriminatory, specific and less frequent clinical signs of this entity (less than 50% of cases) [3,4]. In people with Cushing’s syndrome, in contrast to obesity, stretch marks on the abdomen, breast or upper arms may be greater than 1 cm in width, with a purplish or violaceous appearance [3]. Despite the remission of the glucocorticoid excess the skin lesions are not completely reversible [2]. Treatment lines include topical therapy such as topical retinoids, emollients, salicylic acid, chemical peels including trichloroacetic acid, microdermabrasion, intradermal injection of platelet-rich plasma or carboxytherapy, light therapy including ablative, non-ablative laser therapy, and intense pulsed light therapy, radiofrequency, and filler injection [1].

Conflicts of interest statement: No conflicts of interest.

Funding: There is no source of funding.

Consent: No identifying markers include as part of medical images. No consent required.

References

1. Al-shandawely AA, Ezz Eldawla R, Yassin F, Aboeldahab S. An update in the etiopathogenesis of striae distensae: A review article. Sohag Medical Journal. 2021; 25: 39-44.
2. Valea A, Sandru F, Dumitrascu MC, Albu SE, Carsote M. Striae rubrae: Cushing’s syndrome. Ro J Med Pract. 2019; 14: 447-450.
3. Saranapala M, Torpy DJ. Cushing’s syndrome versus simple obesity. How can a needle be found in the haystack? Endocrinology today. 2015; 4: 30-35.
4. Reincke M, Fleseriu M. Cushing Syndrome-A Review. JAMA. 2023; 330: 170-181.