Endocrine Abstracts

Background: The management of Cushing’s disease can be challenging especially when patients can present with sepsis and severely immunocompromised with limited oral medications to achieve cortisol control. We review a case of Cushing’s disease and the medical management of Cushing’s disease.

Case Report: A 54 year old female presented with symptomatic hyperglycaemia with truncal obesity, proximal muscle weakness, right posterior thorax haematoma and hypertension. Her glycated haemoglobin was 115 mmol/mol, consistent with newly diagnosed Type II diabetes mellitus. She had refractory hypokalaemia and elevated cortisol levels on overnight, low and high dose dexamethasone suppression tests. Pituitary magnetic resonance imaging revealed a 16X 16X 18 mm hypoenhancing lesion on the right pituitary gland with stalk deviation consistent with Cushing’s disease secondary to a pituitary macroadenoma. This was complicated by severe cellulitis from her infected haematoma. Treatment for Cushing’s syndrome was initiated with Metyrapone with cortisol levels improving to nadir of 900 nmol/L. A week later, she developed hospital-acquired pneumonia and acute respiratory distress syndrome with hypoxia requiring intubation and ventilation in the intensive care unit. Due to suboptimal administration of Metyrapone capsules and under-dosing of crushed Ketoconazole tablets through a nasogastric tube, her cortisol levels rose to a peak of 3319 nmol/l. The alternative option of a bilateral adrenalectomy was unsafe given the degree of metabolic decompensation and severe sepsis. Therefore, parental Etomidate was trialled to achieve target cortisol levels of between 600–800 nmol/L. The accumulation of 11b-deoxycortisol interfered with the laboratory assay and a mass spectrometry from another tertiary hospital was utilised to accurately quantify cortisol levels instead. Once stable, she was transferred for a transsphenoidal hypophysectomy at the tertiary centre where she made a good recovery.

Conclusion: This case reviews the treatment options for Cushing’s disease and recommends the use of Etomidate use in challenging cases such as this one.