Endocrine Abstracts

Introduction: Cushing’s disease (CD) is a Grave disease that requires a multidisciplinary and individualized treatment approach.

Case report: We describe the case of a 31-years old female patient with Cushing disease diagnosed in 2007. She initially complained of weight fluctuations, amenorrheia, rounded face with plethora and acne, for 1 year duration. Analytically: 0800 h plasma cortisol of 14 μg/dl (5–25) and 2300 h 15 μg/dl, ACTH 18 and 20 pg/ml, respectively; UFC 420–510 μg/24 h (10–80). Cortisol after LD-DST 3.4 μg/dl and after 2 days LD-DST 13 μg/dl. CRH test: plasma cortisol increased 20% and ACTH 60%. MRI: 5 mm lesion in pituitary left lobe. She was submitted to transphenoidal surgery (TSS) in 2/2008. Pathology: corticotrophinoma. After surgery: 0800 h plasma cortisol 9.4 μg/dl and 2300 h 4.1 μg/dl, ACTH 17 pg/ml and 15 pg/dl; UFC 86 μ/24 h; 2 days LD-DST cortisol<0.1 μg/dl. No residue in MRI. Follow-up until 11/2009 revealed fluctuating clinical symptoms with periods of depression, acne and weight gain. She also had osteoporosis and renal calculi. UFC: 45, 135, 85, 166 and 210 μg/24 h. Plasma cortisol after 2 day LD-DST: 6.6 μg/dl. MRI: possible small lesion, not confirmed in MRI of 3/2010. Nevertheless, in 4/2010 she was submitted to a second TSS, without any corticotrophinoma found. Hormonal evaluation (5/2010): plasma cortisol after 2 days LD-DST of 4.0 μg/dl, UFC 146–275 μg/24 h, no pituitary insufficiencies. Inferior petrosal sinus sampling study wasn’t conclusive. MRI (11/2011) wasn’t suggestive of microadenoma. Since then and until 8/2012, worsening of clinical manifestations: menstrual irregularities, acne, depression, supraclavicular fullness, body bruising and osteoporosis. UFC 330 μg/24 h, 0800 h plasma cortisol 15 μg/dl and ACTH 26 pg/dl. Abdominal CT (7/2012): adrenal glands without alterations. As she maintains active disease bilateral adrenalectomy was proposed, to preserve fertility.

Conclusions: CD remains a challenge at diagnosis and causal treatment. Simultaneously is associated with severe morbidity (and mortality) related with the severity but also with the duration of the hypercortisolism. For young patients preservation of gonadal function is an important issue, leading to the sooner option for bilateral adrenalectomy.