What was causing these symptoms?

Houser had never struggled with her weight before, but she noticed in 2018, months before her wedding, it was starting to increase. In response, she increased the intensity of her workouts and cut her food intake. But still, her weight continued to increase.

Houser wondered if her weight gain was linked to other problems she had experienced in the past. In 2016, Houser started experiencing daily pain in the back of her head, and after the headaches failed to improve after changing her diet and using nonprescription pain relievers, Houser spoke to her primary care doctor and a neurologist.

She noticed the headaches were worse when she wore contact lenses. "It was affecting my daily life and I talked myself into thinking the problem was my contacts," she said. As a result, she got Lasik surgery, which helped improve her vision and cured her headaches for about a week until they returned.

Months later, Houser said she developed "really bad anxiety. It wasn't just like I was anxious," she said. "I couldn't function. I'm Type A so I knew what anxiety is, but not to this degree."

In 2018, she spoke to a psychiatrist and a therapist. The psychiatrist noted Houser's upcoming wedding, saying the event can cause "huge anxiety." Houser started taking an antidepressant as well as Ativan, an anti-anxiety drug.

While Houser's weight was in the normal range, she still couldn't figure out why it was continuing to increase, despite changing her diet and workout. She also noticed her hair, which was typically thick, had thinned so much that her hairdresser suggested she see a doctor.

Houser's psychiatrist suggested the hair loss could be related to her antidepressant and switched her medication, but that didn't change anything.

Following Houser's wedding, she started feeling worse, developing severe insomnia, night sweats, and acne. In February 2019, a nurse practitioner at Houser's primary care practice ordered thyroid tests, which came back normal, and referred Houser to an endocrinologist, who told Houser she was stressed.

Houser then saw a second endocrinologist who agreed with the first one. "She said, 'I don't think there's anything wrong with you,'" Houser said. The second endocrinologist's nurse suggested getting married may be causing stress. "She said, 'I knew on my honeymoon I shouldn't have gotten married,'" Houser remembered her saying. "'Are you in a happy marriage?' I couldn't believe it."

Finally, a diagnosis

In addition to testing her thyroid, Houser's nurse practitioner suggested measuring her cortisol levels. Cortisol is a hormone produced by the body in response to stress and other things. Elevated cortisol levels can be indicative of Cushing's syndrome, an uncommon hormonal disorder that typically results from a tumor, in which the body produces too much cortisol over a long period.

"She had thrown cortisol testing out there and I think it was always in the back of my mind," Houser said.

There are various forms of Cushing's syndrome — the tumors that cause them are typically benign but can sometimes be cancerous and are usually located in the pituitary or adrenal gland, Boodman reports. Sometimes those tumors can develop somewhere else in the body, like the lungs or pancreas. The disease affects around five times as many women as men, usually occurring between the ages of 30 and 50, and can be fatal if left untreated.

Houser asked the second endocrinologist to order cortisol tests. The doctor agreed to the tests but said she didn't believe Houser had Cushing's because she lacked the classic symptoms of the disease, which include major weight gain, purple stretch marks, and a fatty lump between the shoulders. Other symptoms of Cushing's can include insomnia, headaches, acne, and anxiety, Boodman reports. However, Houser did have the "moon face" that is seen in people with Cushing's.

A series of tests revealed elevated cortisol levels in Houser's blood, urine, and saliva, with her urine having cortisol levels eight times higher than normal. The endocrinologist diagnosed Houser with Cushing's and sent her to James Findling, an endocrinologist in Milwaukee who is internationally known for his treatment of Cushing's.

Findling ordered a dotatate PET scan to find where Houser's tumor was, finding it in her left lung. Ultimately, after much deliberation, Houser elected to undergo surgery to remove part of her left lung. A pathologist found the tumor was a rare, slow-growing neuroendocrine lung cancer known as bronchial carcinoid, which can cause Cushing's.

"Fortunately, I think we got it early," Findling said. "She's had a sustained remission and a cure of her Cushing's."

Why did it take so long to diagnose?

Findling estimates he's treated as many as 2,000 people with Cushing's in his 40-year career, and noted that delayed diagnosis is common, because physical changes and other Cushing's symptoms are gradual.

Findling said that, while doctors are taught that Cushing's is a rare disease, it isn't, noting a 2016 study that found 26 of 353 endocrinology patients had the disease.

Descriptions of the disease in textbooks, including the presence of purple stretch marks and a hump, are "almost a caricature," Findling said. "It's pretty well recognized that Cushing's is more subtle than that … and can cause neuropsychiatric and neurocognitive problems."

Findling also noted that Houser "didn't look like the typical Cushing's patient. She wasn't obese and she didn't have diabetes or hypertension. It was more subtle than many cases." It's possible Houser's normal weight and lack of hypertension or diabetes could have misled doctors, Findling said.

"I think we've moved the needle a little bit, especially among endocrinologists," he said, adding that "the threshold for screening has got to change. Once you tell a primary care doctor that it's a rare disorder, it goes in one ear and out the other. They think they'll never see it." (Boodman, Washington Post, 10/7)

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