Endocrine Abstracts

Introduction: Cushing Syndrome have long been recognised to predispose patients to infection diseases, a consequence of the immunosuppression induced by corticosteroids. There is a predisposition to viral, bacterial, parasitic and especially fungal diseases. Opportunistic infections, particularly invasive fungal infections, represent a serious complication associated with an increased risk of mortality.

Clinical case: We represent a 55 years-old woman, poultry farmer, with diabetes diagnosis in January/2017. At September 2017 she was hospitalized at the surgery department (Viseu-Hospital) with an infected diabetic foot ulcer, where she began an intense headache, palpebral ptosis, anisocoria, prostration periods alternated with psychomotor agitation. Cranial CT showed ‘a pituitary expansive lesion, with bone destruction and evidence of bleeding’. Laboratory findings: ACTH 1320 pg/ml (4.7–48.8), TSH 0.07 μUI/ml (0.35–5.5), FT4 0.8 ng/dl (0.9–1.8), prolactin 1.0 ng/ml (1.8–20.3). Patient was transferred to neurosurgery department of Coimbra Hospital with clinical suspicion of pituitary apoplexy, medicated with nasal desmopressin 20 μg 2id, L-thyroxin 50 μg id e hydrocortisone 50 mg 2id. At the neurosurgery department, she repeats laboratory tests: TSH 0.068 μUI/ml (0.4–4.0), FT4 0.9 ng/dl (0.8–1.9), ACTH 41 pg/ml (9–52), cortisol 22 μg/dl (5–25), GH 1.2 μg/l (<1.0), IGF-1 −168 ng/ml (81–225), FSH 4.2 mUI/ml, LH 0.2 mUI/ml, estradiol 17 pg/ml, prolactin 1.1 ng/ml. MRI showed a pituitary macroadenoma with apoplexy (2.7×2.8×3.3 cm). She underwent a transsphenoidal surgery with partial excision of the lesion (October/2017). Neuropathology: a corticotroph adenoma with apoplexy, bone destruction and fungal infection. In February/2017, at the endocrinology department hospitalization, distant fungal infections were excluded with CT scan; blood cultures and HIV were negative. The clinical case was discussed with infectiology physicians and it was decided no initiate anti-fungal treatment. After clinical stabilization, the patient was discharge, medicated with hydrocortisone 15 mg, L-thyroxin 50 μg and sitagliptin 50 mg 2id. She maintains endocrinology and infectiology visits.

Conclusion: The clinical case presented is a rare case of a corticotroph adenoma associated with pituitary fungal infection. The initial clinical suspicion was an apoplexy of pituitary macroadenoma and only neuropathology allowed the correct diagnosis. The pituitary apoplexy associated with surgery allowed the infection removal, the correction of hypercortisolism and glycaemic optimization. The absence of systemic disease made possible to dispense a systemic antifungal therapy. The imaging resolution of the lesion and the persistence of adrenal insufficiency suggest a good prognosis. In conclusion, the professional activity, the hypercortisolism and decompensated diabetes were contributor factors to this rare association.