Endocrine Abstracts

Introduction: Cushing disease, as a state of chronic hypercortisolism, causes diverse, often nonspecific symptoms, possibly delaying the proper diagnosis.

Case report: A 59-year-old woman with the history of type 2 diabetes mellitus, hypertension, osteoporosis and multiannual history of recurrent hospitalizations because of life-threatening multi-sited soft tissue and muscle abscesses, was admitted to the Department of Internal Medicine and Metabolic Diseases due to symptoms of sepsis. A month before the patient was hospitalized in the Department of Surgery because of left buttock abscess. The CT scan revealed iliopsoas and both buttocks abscesses and enlarged left adrenal gland. On admission the patient was in bad condition, lying, requiring other’s help to sit. Physical examination revealed cachexia, thick, atrophic skin with a number of small scars after cutaneous abrasions, excessive chin hair, poor dental condition with severe hypodontia, facial plethora, proximal muscle wasting, arms and legs swelling, deep left buttock abscess cavity. Laboratory tests showed considerably increased inflammatory markers, normocytic anemia, hypoproteinemia with hypoalbuminemia. Blood and abscess cavity swab cultures were positive for MSSA. An abdomen and pelvis CT revealed iliopsoas and both gluteal muscles abscesses and two left adrenal gland lesions (18 × 22 mm and 34 × 22 mm) with density characteristic for adenoma. A pituitary MRI showed a 6mm lesion, described as Rathke’s cleft cyst or atypical microadenoma. The treatment included antibiotics, red blood cell transfusion, negative-pressure wound therapy of abscess cavity and rehabilitation, which led to significant improvement of the patient’s state. We suspected Cushing’s syndrome, however, due to the patient’s serious condition the hormonal diagnostics was postponed. The patient was readmitted to our Department after 3 months in order to perform diagnostics towards Cushing syndrome. The patient was in better condition, without clinical or laboratory signs of inflammation. We observed an increased midnight cortisol, the lack of cortisol suppression in low-dose dexamethasone test and cortisol suppression in high-dose dexamethasone test. The ACTH concentration was 27.98 pg/ml. CRH test revealed over twofold increase in ACTH and cortisol level after stimulation. Hormonal tests indicated Cushing disease. At the Department of Neurosurgery the bilateral inferior petrosal sinus sampling was performed, confirming pituitary source of hypercortisolism. Afterwards, the patient underwent a successful transsphenoidal pituitary surgery. Currently the patient’s condition is still improving, she requires hydrocortisone supplementation.

Conclusions: Presented case shows that recurrent infections should make physicians consider the possibility of Cushing syndrome. It proves that chronic hypercortisolism is destructive and can lead to advanced disability.