Endocrine Abstracts

Cushing’s syndrome results from exposure to excess glucocorticoids. Ectopic Cushings is endogenous ACTH dependant form of Cushing’s associated with markedly raised ACTH and cortisol levels. This leads to an impaired immune response, setting the stage for occurrence of opportunistic infections. Nocardia is a gram positive bacterial infection caused by aerobic actinomycetes in genus Nocardia. We report a series of patients diagnosed with ectopic Cushings, with growth of Nocardia asteroides from pulmonary secretions. In one of these cases, the manifestations of Cushing’s disappeared with treatment for Nocardia. Two middle aged men presented to the Endocrine clinic in the same year: the first with history of exertional shortness of breath, and weight loss for 1 year, the other with facial swelling, disturbed sleep and lethargy for a month. The third case was a young male who presented with progressive weakness & weight loss for some time. All three had uncontrolled hypertension, high blood sugars & were hypokalemic (K: 2.52, 2.9, 1.5; (normal range 3.6–4.0); 24 hour urine cortisol was elevated at 2000, 27,216 and 9088 (32–243); ACTH 68.5, 159, 255(0–48), respectively. Their MRI pituitary was normal, inferior petrosal sinus sampling revealed no central peripheral gradient. CT chest of these subjects demonstrated cavitatory lung lesions; bronchial washings recovered heavy growth of nocardia. Histopathology revealed no malignancy. Antihypertensives, insulin, potassium replacement, ketoconazole & trimethoprim- sulphamethoxole (TS) were initiated. The patients’ symptomatology improved & cavitatory lesions resolved with treatment. The primary source for the ectopic cushings remained unknown. The first case followed a progressively downhill course leading to death. The second case required bilateral adrenalectomy. In the third case, we were able to completely taper off ketoconazole, potassium, insulin & antihypertensives, after starting TS.Opportunistic infections are known to be associated with Cushing’s syndrome, as higher levels of glucocorticoid secretion are found in patients with ectopically produced ACTH. Nocardia of lungs is important differential to consider. This series includes the first case reported in which signs and symptoms of cushings subsided after treatment of Nocardia.

Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.