Introduction: Hypothalamicpituitaryadrenal (HPA) axis activation is the main neuroendocrine response to an environmental challenge. Drug abuse may activate HPA axis by interaction with neuromodulation systems.
Case report: 28 year old man, was admitted in the Neurology Department for persistent headache with spinal irradiation. With suspicion of multiple sclerosis, MRI revealed pituitary macroadenoma (14 mm diameter) and subcortical, paraventricular and frontal white matter demyelinating lesions. Neurological examination excluded multiple sclerosis and he was addressed to the Endocrinology Department. Anamnesis revealed a history of drug abuse (cocaine), alcoholism, chronic smoking (1 pack of cigarettes/day) and depression. Clinical examination revealed moderate weight excess (BMI=27.14 kg/m2) and normal high blood pressure (148/100 mmHg). Hormonal axes were normal, with the exception of the HPA axis: high levels of ACTH (89.2 pg/ml), DHEAS (491.3 μg/dl) and free urinary cortisol (216 μg/24 h), with normal morning and evening cortisol. 1 mg DXM overnight test was negative (cortisol=4.28 μg/dl). It was re-evaluated after one month: persistency of normal cortisol values with constantly moderate high ACTH and good response to 1 mg DXM (1.12 μg/dl). The discordance between ACTH, DHEAS and the rest of HPA axis suggested another possible etiology than an ACTH secretion adenoma (cocaine use, smoking, depression). One year after, biological parameters were constant, with insignificant increase of adenoma (16 mm diameter). Patient denied any further cocaine use for approximately 1 year, but admits that he is still smoking.
Conclusions: The dysregulation of HPA axis may increase vulnerability to depression and numerous other psychiatric disorders, which can be puzzling for the endocrinologists in the diagnosis process. The peculiarity of the case is the association of a pituitary macroadenoma with persistent increased levels of ACTH. Investigations had not confirmed the suspicion of an ACTH secreting pituitary adenoma, and oriented to multiple ethology drug abuse (cocaine, smoking) and depression.
20 May 2017 - 23 May 2017