Endocrine Abstracts

Cushing’s syndrome is associated with life-threatening complications, as well as high rates of perioperative mortality and morbidity. Authors present clinical scenarios, in which one should consider the usage of intravenous etomidate as an accurate, safe and effective drug for hypercortisolaemia.

Case 1: 23-year-old female with severe Cushing’s syndrome due to metastatic adrenocortical carcinoma was admitted to the Department of Endocrinology. She presented with uncontrolled diabetes and hypertension, hypokaleamia, hypocalcaemia and symptoms of an upper respiratory tract infection. Post-adrenalectomy, mitotane, ketoconazole, metyrapone and spironolacton were used to control the disease with poor effect. Her cortisol levels persisted at 90–128 μg/dl, so she was put on the continuous intravenous infusion of Hypnomidate with fast improvement in her clinical condition. She was able to start chemotherapy after one week of etomidate treatment. 8 days later, she was admitted again with chemotherapy-induced leucopenia and diarrhea with electrolyte disturbances. Etomidate infusion was introduced again, until her blood parameters and gastrointestinal symptoms improved.

Case 2: 45-year-old male with the history of recently diagnosed diabetes, refractory hypokalaemia and mild cushingoid features, was admitted to the Department of Endocrinology. Hormonal evaluation revealed ACTH-dependent Cushing’s syndrome. Treatment with ketoconazole was started. In the sixth day of ineffectual oral therapy, the patient’s clinical state deteriorated with fever, spinal pain and exhaustion, due to Staphylococcus aureus sepsis. Cortisol level reached 160 μg/dl, so Etomidate-Lipuro was given intravenously. With short breaks, the infusion was carried on for 50 days. During that time, diagnostic process was completed with the final diagnosis of pituitary corticotropinoma and subsequent effective neurosurgical intervention.

Case 3: 66-year-old female with ectopic Cushing’s syndrome due to metastatic lung carcinoid tumour was referred to the Department of Endocrinology with severe hypercortisolaemia, decompensation of diabetes, deep hypokalaemia and mood disorders. She already had her left adrenal removed 3 months ago. As she was mentally and physically unstable, she was put on Etomidate-Lipuro infusion with an immediate improvement in her status. The course of her hospitalization was complicated with cephalic vein thrombosis, candidiasis, sepsis and post-antibiotic enterocolitis pseudomembranacea, until she was able to undergo complete adrenalectomy (after 58 days of etomidate), without further complications.

Conclusions: In doses far lower than those used for anesthesia, etomidate works as a useful cortisol-lowering therapy in patients intolerant of or unable to take oral medications. Also if urgent medical intervention is necessary, clinicians should be aware of such therapeutical option.