Severe Infection and Electrolyte Imbalances May Signal Cushing’s
Fatal complication followed 'late diagnosis' for 82-year-old woman
A severe muscle infection and electrolyte imbalances were among clinical signs leading to a Cushing’s syndrome diagnosis in an 82-year-old woman, according to a recent case report.
The patient also showed other cardiovascular risk factors for Cushing’s that aided clinicians in their diagnosis. Infectious complications after a surgery caused the woman’s death before treatment could begin.
Her case highlights that “diagnosing and treating [Cushing’s] early is paramount,” the researchers wrote, noting that electrolyte imbalances including low potassium, high sodium, and high bicarbonate levels could be a subtle presentation of the disease.
The case report, “Cushing’s Syndrome Behind Hypokalemia and Severe Infection: A Case Report,” was published in the journal Cureus.
Cushing’s diagnosis based on blood, urine and other test results
Cushing’s syndrome refers to all disorders marked by excessive levels of the hormone cortisol, a condition also known as hypercortisolism.
The most common type of Cushing’s syndrome, Cushing’s disease is usually caused by tumors in the brain’s pituitary gland. These tumors trigger the production of adrenocorticotropic hormone (ACTH), which in turn stimulates the production of cortisol in the adrenal glands that sit atop the kidneys.
Cortisol in excess can affect many bodily systems, but because disease symptoms are often non-specific, a diagnosis can be difficult until serious complications develop.
Chronic, uncontrolled hypercortisolism can lead to complications that include cardiovascular disease and blood clots. Since cortisol suppresses the immune system, hypercortisolism can also raise a risk of serious infections.
An 82-year-old woman in Portugal came to a hospital’s emergency department with complaints of fever and severe pain in her left hip. At her nursing home, she had been given injections of into-the-muscle painkillers.
She was obese, had chronic high blood pressure and type 2 diabetes, as well as multiple non-traumatic bruises and abdominal fat accumulation — all of which can be symptoms of Cushing’s. At the time of admission, she was experiencing hip pain without signs of local inflammation.
A CT scan revealed an abscess — a painful collection of pus indicative of an infection — in the left psoas muscle that runs along the hip joint.
A blood test found signs of inflammation, including a high white blood cell count and elevated C-reactive protein levels.
The woman was treated with broad-spectrum antibiotics, including vancomycin and piperacillin-tazobactam. This was later switched to flucloxacillin when a certain bacteria was identified in her blood.
MRI imaging showed the presence of two more abscesses in the gluteus minimus, another muscle near the hip bone, and inflammation and swelling, or osteomyelitis, of the hip joint.
She also had low blood potassium levels (hypokalemia) resistant to supplements, high sodium levels (hypernatremia), and elevated bicarbonate (metabolic alkalosis) blood levels.
Cushing’s disease possible, but no specific form established
Such electrolyte imbalances have been rarely reported in people with Cushing’s, the scientists noted.
“The aggregation of signs, symptoms and comorbidities in our patient — easy bruising, hypokalemia, metabolic alkalosis, hypernatremia but also diabetes, hypertension and central obesity — raised suspicion of a hypercortisolism state,” they wrote.
Two urinary cortisol tests showed elevated cortisol levels — ranging from 609.1 micrograms (mcg) per day to 1,636.6 mcg/day (normal range: 36–137 mcg/day). Likewise, midnight blood cortisol levels were significantly above the normal range (44.8 mcg/dL; normal range 1.7–8.9 mcg/dL), and a dexamethasone test was positive, indicating the presence of hypercortisolism.
An MRI scan revealed a microadenoma, a small, non-cancerous tumor, in the pituitary gland.
While the specific type of Cushing’s wasn’t established, scientists noted the woman might have “had Cushing’s Disease, given its higher prevalence, the clinical signs of hypercortisolism, and the presence of a microadenoma.”
Still, her low blood potassium levels and severe infection are more consistent with a form of Cushing’s caused by tumors outside the pituitary or adrenal glands, called ectopic Cushing’s, they added.
The abscesses were drained and the woman was treated for five weeks with antibiotics, but surgery was required to avoid re-infection. A fatal infectious complication followed the operation.
“The diagnosis was late, as a life-threatening complication was already present,” the scientists wrote. “In our case, we present a possible presentation of [Cushing’s syndrome] … and highlight the association of a late diagnosis, or long disease duration, with dismal outcomes.”