Endocrine Abstracts

Introduction: A 59-year-old gentleman with longstanding poorly controlled type 2 diabetes mellitus, obesity, hypertension, obstructive sleep apnoea, depression and type 2 respiratory failure was seen in diabetes review clinic and noted to have truncal obesity, moon facies and wasting of the proximal muscles.

Investigations: Urinary free cortisol was 782 nmol/24 h (NR <200). Midnight cortisol was 595 and 532 nmol/l on consecutive days. After low dose dexamethasone suppression test cortisol was 580 nmol/l with ACTH of 130 nmol/l, and cortisol was 159 nmol/l after high dose test. MRI showed a pituitary macroadenoma occupying the pituitary fossa and most of the sphenoid sinus. Trans-sphenoidal hypophysectomy was carried out, and cortisol post-operatively was 60–142 nmol/l. Histology found strong ACTH staining (Ki67 index <3%), and unexpectedly, fungal elements indicating significant infection. The patient was given 4 weeks voriconazole.

Post-operatively regular hydrocortisone was prescribed. The patient lost 20 kg in weight, antihypertensives and insulin requirements reduced by 50% and HbA1c improved from 11.4 to 7.9%. Follow-up scan showed a good surgical result.

Conclusions: There is increased incidence of aspergillosis and fungal infections in Cushing’s syndrome. It is postulated this is due to several effects of glucocorticoids, including reduced lymphocytic activity and proliferation, impaired neutrophilic phagocytosis and impaired macrophage formation of nitric oxide. In addition, glucocorticoids have been shown to directly increase growth of fungal hyphae. Primary pituitary aspergilloma is rarely reported in the literature, all of which have been diagnosed post-operatively and related to spenoidal sinusitis. Sphenoid sinus mass secondary to cryptococcosis and other species have also been reported. If identified, treatment of fungal granuloma should be carried out before removal of pituitary adenomas, to prevent intracranial spread.