Endocrine Abstracts

Introduction: Pituitary ACTH-dependent Cushing’s syndrome (CS) is a condition characterized by an overproduction of cortisol due to pituitary adenoma which infers high morbidity and mortality. Transsphenoidal surgery (TSS) is the first-line therapy of an ACTH-secreting pituitary adenoma. But, even after surgical resection of the adenoma, up to 50% of cases may develop a recurrence of the disease.

Case presentation: A woman, 32 year-old, developed recurrent Cushing’s disease after 6 years remission following TSS for a pituitary microadenoma. The first clinical symptoms appeared at the age of 26 after the pregnancy and birth (cycle disorder, obesity, weight gain by 15 kg, depression). According to medical history: mean 24-hour UFC was 652 719 ng/24 h, Serum cortisol was not suppressed after low-dose dexamethasone suppression testing (191 ng/ml), but was suppressed (28.3 ng/ml) during high-dose dexamethasone testing, Cortisol stimulation after CRF 225 ng/ml basally, maximum 284 ng/ml, ACTH 56.2 pg/ml, after CRF 112 pg/ml, respectively. These results suggested ACTH-dependent CS, underwent TSS. Histopathologic examination confirmed the diagnosis of pituitary adenoma with positive ACTH immunostaining. In the postoperative period there was clinical and laboratory remission, symptoms regressed, weight decreased. She got pregnant in a 2 and 5 years after the surgery, which ended with term deliveries, without complications. A year later, in the postpartum period, clinical signs of hypercortisolism accompanied moon face, and buffalo hump without purple striae, increased weight gain of 10 kg, headaches, and depression. Clinical examination revealed central obesity, moon face, body mass index (BMI) 29.7 kg/m², BP 150/90 mm Hg. A laboratory analysis showed: morning serum cortisol was 530 nmol/l (normal: 171–536 nmol/l), late-night salivary cortisol (LNSC) – 23.1 nmol/l (ref less than 7.56 nmol/l); plasma ACTH was 73.01 pg/ml (normal: 7.2–63.30 pg/ml). Persistent hypercortisolism continued for 7 years. MRI pituitary: no signs of adenoma, but recurrence of ACTH-dependent Cushing’s syndrome was confirmed by CRH stimulation test, inferior petrosal sinus sampling (IPSS) and transnasal adenomectomy was performed. Histopathological examination – microadenoma with positive ACTH immunostaining. In the postoperative period no signs of Cushing.

Conclusion: In this case, pregnancy was a factor of debut and a recurrence of ACTH dependent Cushing’s syndrome.