Endocrine Abstracts

Introduction: Pituitary ACTH-dependent Cushing´s disease and acromegaly are rare conditions. Pituitary adenomas co-secreting GH and ACTH are even more unusual.

Case report: A 29-year-old patient, mother of three children, long-term follow-up by an endocrinologist for a thyroid struma without an autoimmune basis, was sent in April 2023 for further examination for detection of hypercortisolemia and insufficient suppressibility in the overnight 1 mg dexamethason test. The patient reported irregular menstruation, slight weight gain, intense sweating, swelling of her hands and feet. From objective symptoms facies lunata was noticeable, without other remarkable features. According to the diurnal profile of cortisol, the patient did not have preserved circadian variability of cortisolemia, we detected an elevation of cortisoluria, ACTH was within the normal range. On the basis of dexamethasone suppression test, we repeatedly confirmed the diagnosis of ACTH dependent Cushing syndrome, Cushing’s disease. Due to the high level of IGF-1, we repeatedly performed the oral glusoce tolerance test with STH, in which up to the 120th minute there was insufficient suppression of STH. This condition was evaluated as hypersomatotropism. Other pituitary functions were normal. We completed an MRI examination of the pituitary gland because of the suspicion of pathology in this area, which verified two 2 and 4 mm large microadenomas. Than we started treatment with a steroidogenesis inhibitor and a somatostatin analogue before neurosurgery. On 27th of August 2023, transsphenoidal extirpation of both pituitary microadenomas was performed. Histologically, in both material fragments a corticotroph PIT NET, Crookés cell adenoma was verified. Immunohistochemically, growth hormone overproduction was not detected. Four months have passed since the time of diagnosis until the date of the operation. The patient noticed an increase in the size of foot by 1 number. After surgery, there was a remission of acromegaly and Cushing’s disease. Central hypocorticism was newly developed, therefore we started replacement therapy with Hydrocortisone. Subsequently, the patient reported a regular menstrual cycle, less intense sweating, reduction of swelling on the hands and feet. We objectively observed a weight loss of a total of 3 kg in 3 months.

Conclusion : Early detection of two pituitary hormone overproductions and a quick neurosurgical solution protected the patient from the possible development of a number of comorbidities associated with GH and ACTH overproduction. Due to the aggressive variant of corticotroph adenoma, intensive monitoring of the patient will be necessary.