Depression can be an early manifestation of Cushing Syndrome (CS) and found to correlate with the severity of the clinical presentation. Rates for major depression vary from 12% to 5070%. A 37-year-old male was admitted for sad mood, affective lability, suicidal ideation without a plan and micromanian incurability ideation. The medical history of the patient revealed an old anterior-lateral myocardial infarction last year, with percutaneous coronary intervention on diagonal branche D1, hypertension under treatment and type 2 diabetes treated with oral antidiabetic drugs. The relevant clinical signs were overweight, round face and abdominal pain. Laboratory assays revealed hepatic cytolysis (TGP=97 U/l, TGO=61 U/l), cholestasis, inflammatory syndrome, hyperglycemia, A1c of 7.8%, hypopotasemia (K=2.37 mmol/l), with suspicion of CS. Hormonal investigations indicated Cushing-independent-ACTH-syndrome: basal (BC) 87.8 microg/dl, nocturnal cortisol (85.8 microg/dl), free urinary cortisol (1912 microg/24 h) were elevated, low ACTH level (3.15 pg/ml), no suppression at low inhibition test, DHEAS of 5.23 microg/ml, no suppression of the BC at the high dexametasone suppression test. The abdominal ecography showed a left adrenal hypoechoic, homogenous, well diffened tumor of 17/10 cm, retroperitoneal adenopathys, multiple hepatic nodular areas, dilatation of the intrahepatic bill ducts with suspicion of adrenocortical carcinoma with liver metastasis. The thoracic-abdominal computer tomography revealed pulmonary and hepatic metastasis, left renal thrombosis, with extension in the inferior cava vein and the left invasive adrenal tumor. The patient developed suicidal ideation with a plan, requiring urgent antidepressive treatment with serotonin uptake inhibitors, benzodiazepines and hypnotic inducers, which were ineffective. He had to do a biopsy for histopathologic exam, but the general condition of the patient rapidly degraded and contrary to medical efforts the prognosis is very poor; palleativ oncological treatment is expected. Major depression is the most common psychiatric disorder seen in CS, and clinicians should remember that it is necessary to screen a patient with depression and symptoms of CS also for adrenocortical carcinoma.
18 - 21 May 2019
European Society of Endocrinology