Endocrine Abstracts

A 53-year old male presented to his optician with blurring of vision on the right and was diagnosed to have branch retinal vein occlusion. Over the next 6 weeks he manifested further visual impairment, initially due to right central retinal venous occlusion (CRVO) and after another 3 months left CRVO. He received intravitreal Ranibizumab injections and timolol-dorzolamide eye drops in both eyes. Soon after this, he had a hospital admission for infected submandibular gland and was noted to have persistent hypokalaemia and referred to endocrine outpatient. He complained of fatigue, 15 kg weight loss, poor sleep and memory; and had proximal muscle wasting and weakness but no striae or bruising. Investigations confirmed hypercortisolism with suppression of gonadal, thyroid and growth hormone axes. MRI revealed 8×8×12 mm pituitary nodule, which along with >50% suppression of plasma cortisol after high-dose dexamethasone (baseline 861 nmol/L, 48-hour 310 nmol/L) suggested Cushing’s disease. However, acute presentation with rapid weight loss and hypokalaemia raised a suspicion of ectopic ACTH overproduction and he was referred to the regional centre for CRH test with IPSS. However, his health deteriorated rapidly with further weight loss and progressive cognitive decline eventually leading to acute psychosis. He received intravenous Etomidate and on the basis of pituitary MRI scan, emergency transsphenoidal hypophysectomy was performed without IPSS. He had dramatic improvement and all axes other than the adrenal axis recovered. He had complete visual recovery in left eye but unfortunately vision in the right eye is limited to hand movements. This case was unusual because when presented with bilateral CRVO the patient did not manifest any other features of Cushing’s syndrome and only 3 months later he had dramatic weight loss, muscle weakness and acute psychosis. Cushing’s syndrome is a known hypercoagulable state but there is no association in literature with CRVO.