Endocrine Abstracts

Introduction: Hypokalemia is a dyselectrolytemia which can cause weakness, paralysis, neurological symptoms, cardiovascular complications and sometimes can be fatal. It can be diagnosed in uncontrolled diabetes mellitus, hyperaldosteronism, gastrointestinal or renal pathologies.

Case report: A 67 year old female was admitted to the emergency department with confusion, cognitive impairment and headaches and no other known medical history. She presented discrete ecchymoses, discrete facial hirsutism, hypertension 170/110 mmHg, obesity with a BMI of 32 kg/m². Laboratory exams revealed hypokalemia (2.9 mmol/l: normal range 3.6-5.1), metabolic alkalosis and newly diagnosed diabetes mellitus (glycemia 254 mg/dl and Hba1c 10%). She was also diagnosed with severe cognition impairment and depression. Renin and aldosterone levels were normal, but the basal cortisol value was very high (37.3 mg/dl: normal range<20 mg/dl) with high ACTH (108 pg/ml: normal range 7.2-63.3 mg/dl) and also high DHEAS (2 times upper limit of normal value). After the 1mg dexamethasone overnight test the cortisol value was 26.5 mg/dl, after 2×2 dexamethasone test 21.9 mg/dl and after 8×2 high dexamethasone supression test 7.8 mg/dl (supression >50%, but still>1.8 mg/dl). Thorax, abdominal and pelvis computed tomography performed in the ER showed no other tumors. The cerebral and pituitary MRI revealed left sided pituitary microadenoma 5/5/5 mm and a right cerebellopontine angle tumor (neurinoma) of 20/30 mm. After a multidisciplinary team approach we decided to go for transsphenoidal surgery, and in the weeks before the operation she received medical treatment with spironolactone 100mg/day, mifepristone 200mg/day, potassium oral and IV supplementation, antihipertensive medication, antidepressive medication, oral antidiabetics. She performed the surgery, with the pathological exam confirming the diagnosis of pituitary tumor with basophilic ACTH secreting cells. First day after the operation she presented a cortisol level of 1,1 mg/dl and at one week the patient presented low cortisol (3,15 mg/dl) and low ACTH (12,75 pg/ml) with significant improvement of neurocognitive and depressive status, tension and glycemic control. She was discharged with substitutive corticotherapy for secondary adrenal insufficiency (20mg hydrocortisone equivalent to 5mg prednisone per day).

Conclusions: Cushing disease is a very important endocrinological pathology which can present under multiple clinical presentations. It requires an efficient work-up and diagnosis in order to offer the best medical approach available. What is more, the postoperative periodic follow-up is mandatory due to the known risk of recurrence.

Keywords: hypokalemia, neurocognitive impairment, cushing disease