Arthritis after removal of adrenal adenoma in Cushings syndrome
Maria-Christina Ungureanu, Adriana Cernohuz, Carmen Gorduza, Viorel Scripcariu, Carmen Vulpoi & Cristina Preda
Endogenous hypercortisolism is a well-known immunosuppressive condition. Such endogenous cortisol secretion could suppress the clinical presentation of an ongoing autoimmune process.
A 49-year-old woman was admitted in our service in august 2010 for Cushing clinical signs, arterial hypertension and hypokalemia. She had high plasma cortisol not suppressed by 1 and 8 mg dexamethasone overnight, low ACTH. Abdominal computed tomography demonstrated a tumor (3.0×2.7×2.8 cm) in the right adrenal gland. Waiting one month for the surgical cure we initiated treatment with Ketokonazole 800 mg/day but she developed adrenal insufficiency under treatment so we interrupted it. The patient underwent a right adrenalectomy and the diagnosis of a cortisol secreting benign adenoma was histological confirmed. Blood pressure declined and cushingoid features regressed, but 2 months after the operation and while the patient was on replacement, she complained of pain on motion, marked tenderness and swelling of fingers, wrists, elbows, knees and foot joints. We founded normal tests for cortisol, no positive inflation testes except high level of transaminase and positive serology for toxoplasma. Two months of treatment with Rovamicyne normalized transaminases and lowered the titer for toxoplasma antibodies but has no effect at articular level. Rheumatological exam suggest a rheumatoid arthritis with negative rheumatoid factor and treatment with low doses of medrol have a very good effect at joint level.
In summary, we report a patient with Cushings syndrome due to an adrenal adenoma, in which joint symptoms were triggered after curing the hypercortisolism; there are two possibilities of diagnosis: rheumatoid arthritis with negative rheumatoid factor revealed after Cushing therapy or reactive arthritis after toxoplasma infection with no amelioration after antibiotics treatment and no interaction with Cushing disease (but no certain date still now about reactive arthritis and toxoplasmosis).