Case report: Cushing's disease

A 49-year obese woman (BMI 46,6 kg/m²) with diabetes mellitus type 2 and hypertension was referred to our clinic to take part in our program for weight reduction. At presentation the woman showed typical clinical signs of Cushing's syndrome. Basal levels of cortisol and ACTH didn't show any abnormalities, however ACTH was in the upper range. Cortisol was inadequately suppressed after 2 mg dexamethasone. To ensure correct implementation, testing was repeated with inadequately suppression of cortisol again. Measurement of urinary cortisol excretion over 24h showed an elevated quantity. Intravenous application of 100 µg CRH led to an increase of ACTH > 50% and also cortisol rose slightly. The assessment of the testing results pointed to Cushing's disease. NMR of the pituitary gland brought further clearness by showing an adenoma of 11 × 17 × 13 mm. Additional testing of the other pituitary axes showed no insufficiency. The woman was then directed to a neurosurgical departement and transsphenoidal resection of the pituitary adenoma was accomplished. Due to invasive growth into the sinus cavernosus on both sides, an incomplete resection could not be certainly excluded by the surgeon. Histology showed an invasive adenoma with immunhistochemical expression auf ACTH. Unfortunately no remission of disease activity was achieved. So radiotherapy was performed. To bridge the time until the effect of radiotherapy sets in, we began a medical therapy with pasireotide, up to 900 µg twice daily. In the following months medical therapy had to be intensified by adding cabergoline und ketoconazole. This resulted in disease control over several months. But finally hypercortisolism worsened again so that bilateral adrenalectomie was performed.