A 48-year - old woman was admitted in september 2015 for Cushing clinical sings obesity, weight was 120 kg, BMI 44,4 kg/m2, arterial hypertension 160/120 mmHg, hyperlipidemia, moon face, purplish abdominal strie, amenorrhoea, marked swelling of bouth lags, more right leg with varices. Because high D dimer and factor VIII there was suspicion of deep venous thrombosis, Doppler of veins was done immediately wich excludes deep vein thrombosis, and as part of preoperative preparation, the patient was on low molecular weight heparin. She had high 24-h urinary cortisol, plasma cortisol not suppressed by 1 mg dexamethasone overnight (784.7 nmol/l), ACTH less then 1 pg/ml, OGTT test confirmed diabetes mellitus, plasma aldosteron, plasma renin activity and metanephrines were normal, as well as LH, FSH and thyroid hormons. PRL was also low, which significantly cinsidered because patient was treated with bromocriptin from 2004 to 2014 year, after which prolactinoma disapperaed, osteodensitometry has shown osteopenia. Abdominal computed tomography demonstrated a nodule 3.8 cm in the right adrenal gland. She anderwent right adrenalectomy, and histological examination confirmed an adrenal adenoma. Three weeks after the adrenalectomy there was an entrocolitis caused by Clostridium difficile, and she was admitted in state of prostration, febrile, with frequent water diarrhoea, which led to the Addison crisis. Recovery after that was slow, patient was on replacement therapy for next six months. Total colonoscopy was normal, and on gastroscopy gastroduodenitis is found. Eight months after biochemical and clinical resolution of hypercortrisolism blood pressure fell on 120/80 mmHg, cushingoid features regressed completely, she lost 64 kg of body weight, and kept the same weight until 2019 year, the lipid profile was normalised, and remaind normal, blood sugar has normalized, edema and enlarged veins disappeared, the menstruial cycle again became regular, only depression has occurred and patient is constantly under therapy. Two months after termination of replacement therapy she complained of back pain, pein on motion, marked tenderness, swelling of fingers and pain of the first and second metacarpophalangeal joint. Rheumatological exam suggest a rheumatoid arthritis with highly positive rheumatoid factor and C reactive protein, cystic erosiones of PIP and DIP joints, ANA were negative, terapy with Metotrexat 7.5 mg weekly is still in progres, without corticosteroids, and have a very good effect at joint level. In conclusion after treatment of Cushing syndrom patients shoud be evaluated for development of autoimmune disorders in order to obtain early diagnosis and proper treatment.
18 - 21 May 2019
European Society of Endocrinology