Endocrine Abstracts

JOINT3322

Cushing syndrome is characterized by specific clinical features and several complications, including diabetes mellitus, hypertension, infections, electrolyte imbalances and pro coagulant status. In these patients, cardiovascular risk and mortality rates remain high (~10%) despite surgical cure, mainly because of the associated complications. We report the case of a 53-year-old male, who was simultaneously diagnosed with type 2 diabetes mellitus and arterial hypertension two years ago. He was referred to our Clinic from the Oro-Maxillo-Facial Surgery department, where he was admitted for multiple dental abscesses. There, hypokalemia (2.3mmol/l) was detected, as well as maximum systolic blood pressure of 180mmHg despite treatment with 3 antihypertensive medications. Biologically, we note an HbA1c level of 8.1%, despite treatment with two oral antidiabetic medications and adherence to dietary recommendations. Endocrinological assessment identified classical features of Cushing syndrome (full moon facies, buffalo hump, proximal myopathy and truncal obesity). Hormonal evaluation confirmed ACTH independent Cushing syndrome (ACTH 9pg/mL, AM cortisol 25.1mg/dL, PM cortisol 24.8mg/dL, no inhibition after 1 and 8mg dexamethasone tests); and secondary hypogonadism and hypothyroidism. The abdominal CT scan identified a 4cm right adrenal adenoma, and the patient was scheduled for surgery one month later. During this time he developed jaundice and hepatic cytolysis (maximum liver enzyme levels – 386U/l, normal hepatic profile at diagnosis), for which toxic, infectious and immunological causes were excluded. During the same time frame, the patient developed plurimicrobial, bacterial cellulitis in both arms (Escherichia coli, Staphylococcus aureus), for which hospitalization and IV antibiotics were necessary, with favorable evolution. Following surgery, treatment with Prednisone was initiated, in gradually decreasing doses until ACTH stimulation test confirmed proper hypothalamic-pituitary-adrenal axis function, so treatment was stopped. Additionally, liver function tests normalized postoperatively, suggesting that liver injury was most likely caused by Cushing-related metabolic dysfunction; systolic blood pressure dropped to around 120-130mmHg, despite a reduction in treatment; and HbA1c levels dropped from 8.1% to 4.7%, so antidiabetic medications were stopped. In conclusion, Cushing syndrome can cause a series of complications which can delay surgical treatment. Our patient developed a series of unusual complications, including plurimicrobial bacterial cellulitis in both arms and metabolic-associated hepatic injury, with normalization of liver function tests after surgery. In conclusion, swift surgical intervention, close monitoring and a highly skilled interdisciplinary team is necessary for managing these patients and the various complications that can arise secondary to Cushing syndrome.