Endocrine Abstracts

Introduction: The pseudo-Cushing’s encompass several disorders that can occur in high-stress situations, such as the sepsis, and that show biochemical features like those of Cushing’s syndrome. We present a case with difficult differential diagnosis, for overlapping laboratory findings.

Case description: A 74-year-old man was admitted to our hospital for worsening dyspnoea since a month, 15 kilograms weight loss in the previous months, asthenia, hypotonia and muscle hypotrophy. In past medical history: glucose intolerance in treatment with metformin, depression in treatment with mirtazapine and vortioxetine and pancreatic intraductal papillary mucinous neoplasm (IPMN). Due to the onset of acute hypoxic-hypercapnic respiratory failure, the patient was treated with not-invasive ventilation and then admitted to the intensive care united, for pneumonia and respiratory failure due to Meticillin-sensitive Staphylococcus aureus (MMSA) and Klebsiella Aerogenes. Antibiotic therapy was started according to the results of the antibiograms and sepsis. The neurological assessment showed a severe strength deficiency of the neck flexors and four limbs and hypophonia, reflexes were not revocable. No abnormalities in ocular motility, palpebral ptosis and muscular or lingual fasciculations were detected. Electromyography of deltoid muscles, brachial biceps and right rectus femur documented a method of recruitment of the myopathic type, suggestive for a sporadic late onset nemaline myopathy (SLONM). During the treatment in ICU, the patient underwent endotracheal intubation for the worsening of respiratory function and inotropic drug therapy was introduced for the development of septic shock. According to patient’s clinical condition, hormones were tested showing an ACTH-dependent hypercortisolism. The results of Nugent, Liddle and the dexamethasone suppressed CRH stimulation tests suggested a not-neoplastic ACTH-dependent hypercortisolism. The pituitary contrasted magnetic resonance image showed a gland hypertrophy and the abdominal computed tomography (CT) ruled out adrenal lesions. Unfortunately, the patient developed a multi-organ failure, and at least died. The autopsy finding confirmed the absence of pituitary and other neuroendocrine tumours and showed a bilateral adrenal hypotrophy.

Conclusions: Our clinical case described a patient with pseudo-Cushing’s syndrome during sepsis and pre-agonist phase, with difficult differential diagnosis, in which the combination of the low-dose dexamethasone suppression test and the CRH test allowed a conclusive and correct diagnostic orientation.