Diagnosis of Cushing's disease in a patient with consistently normal urinary free cortisol levels: a case report

Rare Challenges in Diagnosing Cushing's Syndrome and Primary Aldosteronism: A Case Report of a Female With a Negative Workup

Cushing's syndrome with concurrent primary aldosteronism (PA) is a rare presentation, and establishing an early diagnosis is imperative to preventing morbidity and long-term sequelae. The diagnosis is established by sequential lab work, showing an elevated cortisol and aldosterone level. Taking the above into consideration, it is evident that repeatedly negative results on all three tests can present an extremely challenging case. In this report, we discuss a female who presented with an adrenal incidentaloma and features suggestive of primary hyperaldosteronism as well as Cushing's syndrome but no elevations in serum, urine, or salivary cortisol. In this study, we present a 37-year-old female with resistant hypertension and tachycardia. She had several features suggestive of Cushing's syndrome including resistant hypertension, proximal muscle weakness, weight gain, easy bruising, hair loss, and a history of tachycardia and chest pain. Examination revealed an obese female with thin silvery abdominal striae. The patient's labs revealed normal serum cortisol, urine-free cortisol (UFC), late-night salivary cortisol, and a normal dexamethasone suppression test. An abdominal computed tomography (CT) scan revealed a right adrenal mass measuring 2.1 x 1.5 x 2.5 cm. Due to a high index of suspicion, adrenal venous sampling was performed, which revealed high levels of cortisol and aldosterone in the right vein, confirming the diagnosis. The patient subsequently underwent a right adrenalectomy. She developed hypotension post-op, leading to the diagnosis of glucocorticoid-remediable aldosteronism.

Nelson-Salassa Syndrome Progressing to Pituitary Carcinoma: A Case Report and Review of the Literature

Nelson-Salassa Syndrome (NSS) is a rare sequela of bilateral adrenalectomy as a treatment for persistent hypercortisolism in refractory Cushing disease (CD). Radiographic NSS has been observed in half of CD patients after adrenalectomy, yet often follows a mild course and rarely requires treatment. We present the case of a 44-year-old male with a history of CD who underwent primary treatments including transsphenoidal resection, radiotherapy, and bilateral adrenalectomy. He subsequently presented with acute vision loss and progressive somnolence. MRI revealed marked enlargement of an invasive sellar and suprasellar lesion exerting significant mass effect on the chiasm, and multiple new enhancing bony lesions. The patient was taken for emergent transsphenoidal resection and calvarial biopsy; visual function was restored postoperatively, and pathologic analysis confirmed pituitary carcinoma. While NSS typically follows an indolent course, pituitary carcinoma is a highly morbid metastatic disease, and has been theorized to occur at a higher frequency in the NSS population. We review all published cases of NSS to pituitary carcinoma progression, which further underscores the highly aggressive nature and considerable mortality of this patient cohort. Although mild, asymptomatic NSS is more commonly observed, symptomatic patients or those with rapid growth after adrenalectomy, should be targeted for routine close clinical follow-up and serial radiographic surveillance.