Endocrine Abstracts

Introduction: Pseudo Cushing syndrome (PCS) is caused by non-neoplastic over activity of the hypothalamic-pituitary-adrenal axis. Differentiating between PCS and Cushing disease (CD) can be challenging because of their overlapping clinical and biochemical features.

Case presentation: 15 year old male presenting with watery diarrhea of 2 months duration occurring 3 times per day with lower limb weakness No rectal bleeding, fever, or weight loss

Physical examination: Blood pressure: 125/90 mm Hg. Pulse: 125 /mint, normal RR and temperature. BMI: 41 kg/m2 and no cushingoid features. The abdominal examination showed hepatomegaly. The neurological examination showed nystagmus and decreased motor power of both L.L (grade 1) with intact sensations. The Cardiac and chest examination were normal. Investigations: Labs: Infectious work-up including ova and parasites, culture were negative (Hb 9.9 gm/dl), microcytic hypochromic anemia hypokalemia (2.5 mEq/l) (3.5-5.5 mEq/l) hypoalbuminemia (2.7 mmol/l), Normal liver and kidney functions Anti-transglutaminase, and anti-endomysial antibodies, ANA, ANCA, LKMA, ASMA were also negative. Colonoscopy revealed erythematous mucosa in the transverse colon, Esophagogastroduodenoscopy (EGD) revealed diffuse gastric erythema with erosions and duodenitis, cortisol was done to exclude adrenal insufficiency instead it was markedly elevated Serum cortisol 9 am: 48.23 mg/dl (4.3-22.4), cortisol 9 pm: 40.73 mg/dl (> 10), ACTH: 89.3 pg/ml (7.2-63.3), free urinary cortisol < 1140 mg/24 hr Serum cortisol 9 am after low dose dexamethasone suppression test:30.2 mg/dl Serum cortisol 9 am after high dose dexamethasone test: 3.18 mg/dl Imaging: Abdominal CT with oral and I.V contrast: hepatomegaly (27 cm), enlarged celiac and porta hepatis lymph node (largest 1.7 cm) Biopsy of porta hepatis lymph node: non-caseating microgranulomas picture of sarcoidosis Angiotensin-converting enzyme (ACE) was elevated at 93 U/l (8-52), Chest CT was unremarkable and the patient started to receive 40 mg prednisone Outcome and follow up: The diarrhea stopped, L.L weakness improved (grade 4) as well as the anemia (Hb 12 gm/dl). Morning cortisol 14.5 mg/dl. ACTH 37.2 pg/ml

Conclusion: We present a case of PCS with severe hypercortisolism mimicking CD in critical ill adolescent with GIT sarcoidosis that improved spontaneously with the treatment of underlying aetiology