Endocrine Abstracts

Background

Cardiovascular complications of Cushing’s syndrome (CS) include; hypertension, left ventricular hypertrophy, and myocardial ischaemia. Also, CS can cause structural and functional changes in the heart, leading to dilated cardiomyopathy in rare cases. Here, we present a case with dilated cardiomyopathy related to Cushing’s syndrome.

Case

A 31-year-old male patient applied to the cardiology department with shortness of breath that worsened with exertion for a year. Globally advanced hypokinetic and globally dilated heart was found in echocardiography with ejection fraction (EF) 20%. His medical treatment was arranged by cardiology department and referred to endocrinology clinic due to the 25 kg weight gain in one year, increased appetite and purple striae on the abdomen and shoulder. Laboratory tests revealed that; ACTH was <5 pg/ml, cortisol: 24.3 µg/dl, night cortisol: 24.7 µg/dl. After 1 mg dexamethasone suppression test (DST) and, 2 day 2 mg DST cortisol levels were found 18.9 µg/dl and 31.79 µg/dl, respectively. Because these findings suggest the CS, abdominal MRI was performed and revealed that a mass lesion (adenoma?) with a smooth contour, 37 × 28 mm in size, showing heterogeneous signal loss in the outer phase in the left adrenal gland. No pathological finding was found in pituitary MRI. With these findings, the patient was diagnosed with adreanal Cushing Syndrome. Viral myocarditis, lupus or autoimmune myocarditis was ruled out by negative viral respiratory panel, and negative autoimmune panel respectively. Absence of hilar adenopathy excluded sarcoidosis. Cardiac MRI conducted for cardiac exclusion of mixoma and revealed no findings that were consistent with the mixoma. After the exclusion of other reasons of cardiomyopathy the patient was diagnosed with dilated cardiomyopathy. In the control echocardiography 2 months after heart failure treatment, EF was found 40%. Metyrapone therapy was started gradually to lower the risk of surgery by lowering the patient’s preoperative cortisol load. The cortisol level was found to be 17.4 µg/dl, 2 hours after the first metyrapone treatment. 10 days after metyrapone treatment, when the cortisol level decreased by 14.8 µg/dl, left adrenal gland excision was performed. Postoperative cortisol was found to be 1.8 µg/dl and 3.2 µg/dl. Pathology result was compatible with nodular diffuse hyperplasia.

Conclusion

Dilated cardiomyopathy and left ventricular failure are rare presentations of CS. Since cardiomyopathy can be reversed following successful treatment of Cushing’s syndrome it is important to consider this diagnosis in patients with both heart failure and signs of CS.