Recurrence of hypercortisolism after long-term post-transsphenoidal surgery remission in a patient with Cushing disease

Barbuceanu Anca Lorena; Constantin Cucu

doi:10.1530/endoabs.73.EP172

Selective transsphenoidal resection of the pituitary adenoma is the initial treatment of choice for Cushing disease. Although the achievement of low cortisol levels following transsphenoidal surgery for Cushing disease is associated with surgical success, recurrence can still occur.

Case presentation

A 38 years old female patient, known with Cushing disease, secondary hypertension, type 2 diabetes and osteopenia, is admitted to our clinic in march 2019, after the second transsphenoidal surgery with symptoms suggesting a cortisol deficiency (nausea, vomiting, fatigue). The patient had her first transsphenoidal surgery in 2010, after which she also presented cortisol deficiency with the recovery of the hypothalamic–pituitary–adrenal axis after 1 year and maintenance of remission for several years.


	10.2010	01.2011	06.2011	09.2011	01.2017	07.2017	02.2019	03.2019
Cortisol 800 (n 4.8–19.5 μg/dl)	33.77	0.78	2.70	6.25	10.54	12.09	17.5	0.37
ACTH 800(n 4–66 pg/ml)	68.42	–	11.22	18.68	36.35	49.95	39.83	8.3
Cortisol after DXM 2Χ2	17.56	–	–	–	2.78	2.6	4.39	–
Urinary free cortisol (n = 21–111 μg/24 h)	–	–	–	–	108.64	98.28	–	–
Imagistic exam (pituitary adenoma dimensions on CT or MRI)	0.8/0.69 cm	0.38/0.25 cm	–	–	0.7/0.4 cm	–	0.6/0.5 cm	0.37/0.27 cm
Secondary comorbidities					Newly diagnosed hypertension (maximal value 220/110 mmHg)		Newly diagnosed diabetes (HbA1c = 7.2%, a jeun glycemia = 138 mg/dl) and hypercholesterolemia

Clinical exam

BP = 140/80 mmHg, HR = 80 bpm, cushingoid facial features, axillary acanthosis nigricans, no headache, no visual field disturbance, central redistribution of obesity, reduction of muscle strength, no new stretch marks, old, whitish stretch marks with loss of substance on the lower abdomen, hyperpigmented areolas, regular menses.

Biochemical tests

secondary adrenocortical insufficiency, normal gonadotrophin levels, normal thyroid function

Treatment

Prednisone 5 mg per day was started and follow-up after 3 months was recommended

Conclusion and discussion

Patient diagnosed with Cushing disease 10 years ago, who seemed in remission after the first TS surgery, returned after 5 years with newly diagnosed hypertension, without any other clinical signs of Cushing and a non-suppressible cortisol value, but a normal urinary free cortisol. We recommended the patient to come for reassessment after 3 months, but she did not comply and returned after 2 years with newly diagnosed diabetes, Cushing phenotype and greater hypercortisolism. Even if the patient with Cushing disease seems to evolve favorably post-TS surgery, the long-term follow-up for the possibility of recurrence is needed.

Endocrine Abstracts

EP172