Spontaneous Resolution Of Primary Hypercortisolism Of Cushing Disease After Pituitary Hemorrhage
Siwakoti, K., Omay, S. B., & Inzucchi, S. E. (2020). SPONTANEOUS RESOLUTION OF PRIMARY HYPERCORTISOLISM OF CUSHING DISEASE AFTER PITUITARY HEMORRHAGE. AACE clinical case reports, 6(1), e23–e29. https://doi.org/10.4158/ACCR-2019-0292
View Original Source →Abstract
We report a case of spontaneous resolution of CD from symptomatic hemorrhage within an ACTH-secreting pituitary adenoma, or PA. This has been rarely reported in the medical literature. The fact that she did not pass through a phase of adrenal withdrawal, makes us suspect a residual functional adenoma within or around the sella which may eventually grow, causing her disease to recur, as has been reported. Hence, continued monitoring will be required.
Case Details
Disease Location
Pituitary gland
Personal Characteristics
59-year-old female with a past medical history of hypertension (triamterene-hydrochlorothiazide), diabetes mellitus type 2 (insulin glargine 25 units daily and insulin lispro 6 units 3 times daily before meals, in addition to metformin) gastroesophageal reflux disease, bilateral cataracts, and obstructive sleep apnea. Family history of brain aneurysmal rupture
Clinical Characteristics
Acute onset diffuse headache, associated with nausea and dizziness. The headache was left-sided and radiated to the face and jaw. Head CT revealed a mass within the sella. Her neurologic examination was within normal limits. MRI revealed a heterogeneous mass within the sella, which was non-enhancing on postcontrast imaging measuring 1.5 × 1.9 × 2.3 cm extending into the supra-sellar region, but not compressing the optic chiasm. Neurovascular imaging was normal. Laboratory testing included elevated plasmatic cortisol and a 24-hour urine free cortisol (ufc) strikingly high. Plasma cortisol did not suppress during an overnight low-dose (1 mg) dexamethasone suppression test (dst). On further testing, plasma acth was high. Free t4 was at the upper limit of normality. Borderline elevation of insulin-like growth factor 1. When seen in the endocrinology clinic 3 weeks after discharge, the patient related a 20 pound weight gain over the previous year, and new rounding and ruddiness of her face, as well as fatigue. She appeared cushingoid with centripetal obesity, moon facies, plethora, and a buffalo hump,
Remission Characteristics
After the endocrinology consultation, on repeat laboratory testing, she was noted to have a normal am cortisol and normal urine free cortisol. Igf-1, free t4, and tsh were also within normal ranges. 3 months later a MRI brain scan, revealed an interval decrease in the size of the pituitary lesion, now measuring approximately 11 mm in craniocaudal dimension. Extension to the optic chiasm was no longer present. Additionally, a hypoenhancing region below the gland was noted, scalloping the sphenoid bone suggestive of residual adenoma and measuring approximately 8 mm in diameter
Treatment & Mechanisms
Proposed Remission Mechanisms
Auto-infarction of her adenoma
Clinical Treatment
Dexamethasone sd (multiple times for dexamethasone suppression test)