Life-threatening complications of Cushing's syndrome: a case report
Introduction (case reports only) Cushing’s syndrome (CS) is a rare disease, characterized by elevated cortisol levels in the blood. ACTH-secreting tumours sometimes can be difficult to identify and persistent hypercortisolism may lead to serious complications. Case description (case reports only) A 31-year-old man presented complaints of excessive weight gain, fatigue, and limb weakness in 2009. Clinical examination revealed reddish-purple striae and he was found to have hypertension. In 2014 patient was diagnosed with type 2 diabetes. Laboratory tests showed normal range of cortisol, elevated ACTH (71,5 ng/l (n.r. 1.63-14.15)), and loss of cortisol diurnal rhythm (morning cortisol: 565 mmol/l (n.r. 177-578), late-night cortisol: 429 mmol/l). During this time, the patient was admitted to intensive care unit (ICU) due to bilateral pneumonia, sepsis, septic shock, and multiple organs dysfunction syndrome. After recovery, ACTH level remained elevated (103 ng/l). Additionally, low-dose and high-dose dexamethasone suppression tests were performed, which suspected ectopic ACTH secretion. However, ectopic tumour was not identified despite extensive laboratory, endoscopic, and imaging examinations. Treatment with metyrapone was initiated. In 2018 the patient was treated in ICU for the second time due to pneumonia and pyelonephritis complicated with sepsis and septic shock. Eventually, mixed-hypertensive nephropathy, caused by difficult-to-control hypertension and complications from previous infections, led to stage 5 chronic kidney disease requiring hemodialysis. In 2019, due to insufficient control of hypercortisolism, bilateral adrenalectomy was performed and treatment with hydrocortisone was initiated. Adrenalectomy resulted in improved well-being, however, the cause of CS was not found despite repeated extensive examinations. Summary (case reports only) This clinical case demonstrates that persistent hypercortisolism may result in acute and life-threatening complications. Conclusions Bilateral adrenalectomy should be considered as a treatment option in the most complicated hypercortisolism cases.