Endocrine Abstracts

We report the case of a 47-year-old woman with a 5-year history of weight gain, resistant hypertension and uncontrolled type 2 diabetes. She complained of oligomenorrhoea, depression and had a strikingly Cushingoid appearance and so underwent evaluation for Cushing’s Disease.

Investigations revealed elevated 24-hour urine free cortisol (UFC) collections on 2 occasions: 540 nmols/24h and 624 nmols/24h. Overnight dexamethasone suppression testing (ODST) showed elevated 9 am cortisol concentrations of 671 nmol/L and 790 nmol/L. Cortisol failed to suppress following a 2-day low dose dexamethasone suppression test (LDDST)- post LDDST cortisol 125 nmol/L. Following a high dose dexamethasone suppression test (HDDST) the cortisol did suppress to 43 nmol/L. ACTH was high at 7 mU/L and then 5 mU/L at 9 am on 2 occasions.

3T MRI of pituitary revealed a left sided inferoposterior microadenoma. Bilateral inferior petrosal sinus sampling (BIPSS) was unsuccessful. CT Thorax revealed no ectopic source of ACTH secretion.

Transphenoidal left sided hemi-hypophysectomy was performed and pathology confirmed a pituitary microadenoma with positive immunostaining for ACTH. Day 3 postoperative serum cortisol was <30 nmol/l and replacement Hydrocortisone was commenced.

The patient was frequently readmitted to hospital with systemic illnesses of unclear aetiology and complained of myalgia, arthralgia, lethargy and breathlessness with no evidence of sepsis or overt hypocortisolism. CT Thorax was repeated, owing to breathlessness and a normal CXR, and showed new bilateral mediastinal and hilar lymphadenopthy. Serum ACE was elevated. Epitheloid granulomas in keeping with sarcoidosis were demonstrated on hilar biopsy.

The unveiling of a steroid responsive disease post treatment for CD is rare. Sarcoidosis has been reported as a sequel with dermatological signs but here were absent with only a generalised systemic illness with hilar and mediastinal lymphadenopathy seen. The convalescent period following treatment for CD can be stormy and consideration must occasionally be given to unusual diagnoses.