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Aladwani MM, Alrubaiaan MT, Alrayani YH, Alabdali TN. Adrenocorticotropic Hormone-Dependent Cushing's Syndrome Complicated With Gastric Ulcer Perforation in a 30-Year-Old Saudi Female: A Case Report and a Review of the Literature. Cureus 2023; 15:e48089. [PMID: 38046760 PMCID: PMC10690111 DOI: 10.7759/cureus.48089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Gastrointestinal perforation is a well-addressed complication of exogenous hypercortisolism; however, patients with endogenous Cushing's syndrome (CS) do not usually experience this condition in clinical practice. The literature on this subject is limited and consists solely of clinical case reports/series with only 23 instances of gastrointestinal perforation occurring in individuals with endogenous Cushing's syndrome. This is mainly attributed to the rarity of Cushing's syndrome itself and the low chance of occurrence of such complications. We report a case of a recently diagnosed adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome in a 30-years-old female who presented initially with a three-month history of progressive weight gain, generalized weakness, acne, menstrual irregularity, and severe hypokalemia, and then developed a gastric ulcer perforation only one month after her ACTH-dependent Cushing's syndrome diagnosis and was managed through emergent surgery.
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Affiliation(s)
| | - Mishari T Alrubaiaan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Yazeed H Alrayani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Tareq N Alabdali
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
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Ishinoda Y, Uto A, Meshino H, Kobayashi A, Okazaki M, Asada H, Wakamatsu S, Tsuda H, Yamada Y, Kasuga A, Oshima N. Bowel perforation associated with Cushing's disease: a case report with literature review. Endocr J 2023; 70:933-939. [PMID: 37380447 DOI: 10.1507/endocrj.ej23-0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Abstract
Although rare, endogenous hypercortisolemia, including Cushing's disease (CD), is known to cause bowel perforation and to mask typical symptoms of bowel perforation, leading to delayed diagnosis. Additionally, elderly patients with CD are considered to be at a higher risk for bowel perforation because intestinal tissue fragility tends to increase in the elderly. Herein, we describe a rare case in which a young adult patient with CD was diagnosed with bowel perforation associated with CD following severe abdominal pain. A 24-year-old Japanese man was admitted to the hospital for the evaluation of ACTH-dependent Cushing's syndrome. He suddenly complained of severe abdominal pain on the 8th day of hospitalization. Computed tomography revealed free air around the sigmoid colon. The patient was diagnosed with bowel perforation, underwent emergency surgery, and was saved. He was subsequently diagnosed with CD, and the pituitary adenoma was resected transsphenoidally. To date, eight cases of bowel perforation due to CD had been reported, with a median age of 61 years at the time of bowel perforation. Hypokalemia was detected in half of the patients, and all had a history of diverticular disease. Nevertheless, not many patients complained of peritoneal irritation. In conclusion, this is the youngest reported case with bowel perforation due to CD and the first report of bowel perforation in a patient without a history of diverticular disease. Bowel perforation may occur in patients with CD, irrespective of age and the presence of hypokalemia, diverticular disease, or peritoneal irritation.
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Affiliation(s)
- Yuki Ishinoda
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Asuka Uto
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Hitomi Meshino
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Ai Kobayashi
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Maki Okazaki
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Hidetomo Asada
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Seina Wakamatsu
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Hitoshi Tsuda
- Department of Basic Pathology, National Defense Medical College, Saitama 359-8513, Japan
| | - Yoshifumi Yamada
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Akira Kasuga
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
| | - Naoki Oshima
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama 359-8513, Japan
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Intestinal Perforation in ACTH-Dependent Cushing's Syndrome. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9721781. [PMID: 31001560 PMCID: PMC6436364 DOI: 10.1155/2019/9721781] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 02/21/2019] [Indexed: 01/25/2023]
Abstract
Previous studies have linked systemic glucocorticoid use with intestinal perforation. However, the association between intestinal perforation and endogenous hypercortisolism has not been well described, with only 14 previously published case reports. In this study, we investigated if intestinal perforation occurred more frequently in patients with ectopic ACTH syndrome and in those with a greater than 10-fold elevation of 24-hour urinary free cortisol level. Of 110 patients with ACTH-dependent Cushing's syndrome followed in two clinics in Canada, six cases with intestinal perforation were identified over 15 years. Age of patients ranged from 52 to 72, five females and one male, four with Cushing's disease and two with ectopic ACTH production, one from a pancreatic neuroendocrine tumor and one from medullary carcinoma of the thyroid. Five had diverticular perforation and one had intestinal perforation from a stercoral ulcer. All cases had their lower intestinal perforation when the cortisol production was high, and one patient had diverticular perforation 15 months prior to the diagnosis of Cushing's disease. As in previously reported cases, most had hypokalemia and abdominal pain with minimal or no peritoneal symptoms and this occurred during the active phase of Cushing's syndrome. Whereas all previously reported cases occurred in patients with 24-hour urinary free cortisol levels greater than 10-fold the upper limit of normal when measured and 11 of 14 patients had ectopic ACTH production, only one of our patients had this degree of hypercortisolism and four of our six patients had Cushing's disease. Similar to exogenous steroid use, patients with endogenous hypercortisolism also have a higher risk of intestinal, in particular diverticular, perforation and should be monitored closely for its occurrence with a low threshold for investigation and surgical intervention. Elective colonoscopy probably should be deferred until Cushing's syndrome is under control.
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Sater ZA, Jha S, McGlotten R, Hartley I, El Lakis M, Araque KA, Nieman LK. Diverticular Perforation: A Fatal Complication to Forestall in Cushing Syndrome. J Clin Endocrinol Metab 2018; 103:2811-2814. [PMID: 29846662 PMCID: PMC6276718 DOI: 10.1210/jc.2018-00829] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/23/2018] [Indexed: 12/26/2022]
Abstract
CONTEXT Patients taking exogenous glucocorticoids are at risk for gastrointestinal (GI) complications, including peptic ulcer disease with perforation and gastric bleeding. However, little is known about the GI comorbidity in patients with endogenous hypercortisolemia. CASE DESCRIPTIONS We describe six patients with endogenous Cushing syndrome (CS) who developed sudden perforation of colonic diverticula necessitating urgent exploratory laparotomy. Most of these patients shared the following features of CS: skin thinning, severe hypercortisolemia (24-hour urinary free cortisol ≥10 times the upper limit of normal), ectopic secretion of ACTH, and severe hypokalemia. At the time of diagnosis of diverticular perforation (DP), these patients had minimal signs of peritonitis and lacked fever or marked leukocytosis. The diagnosis of DP was established by having a low threshold for obtaining an imaging study for evaluation of nonspecific abdominal pain. CONCLUSIONS Patients with CS can develop spontaneous surgical abdomen with rapid decompensation within hours. Prompt recognition is critical in the successful treatment of these patients.
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Affiliation(s)
- Zahraa Abdul Sater
- Diabetes, Obesity and Endocrinology Branch, National Institute of Diabetes and
Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Smita Jha
- Diabetes, Obesity and Endocrinology Branch, National Institute of Diabetes and
Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
- Clinical and Investigative Orthopedics Surgery Unit, National Institute of
Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda,
Maryland
- Correspondence and Reprint Requests: Smita Jha, MD, 10 Center Drive, Building 10-CRC, Room 4-1341, MSC 1468, Bethesda,
Maryland 20892. E-mail:
| | - Raven McGlotten
- Diabetes, Obesity and Endocrinology Branch, National Institute of Diabetes and
Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Iris Hartley
- National Institute of Child Health and Human Development, National Institutes
of Health, Bethesda, Maryland
| | - Mustapha El Lakis
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland
| | - Katherine A Araque
- Diabetes, Obesity and Endocrinology Branch, National Institute of Diabetes and
Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Lynnette K Nieman
- Diabetes, Obesity and Endocrinology Branch, National Institute of Diabetes and
Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Kaya T, Karacaer C, Açikgöz SB, Aydemir Y, Tamer A. Severe Hypokalaemia, Hypertension, and Intestinal Perforation in Ectopic Adrenocorticotropic Hormone Syndrome. J Clin Diagn Res 2016; 10:OD09-11. [PMID: 26894113 DOI: 10.7860/jcdr/2016/17198.7127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 11/27/2015] [Indexed: 01/19/2023]
Abstract
Ectopic adrenocorticotropic hormone (ACTH) syndrome is a rare cause of the Cushing's syndrome. The occurrence of the ectopic ACTH syndrome presenting with severe hypokalaemia, metabolic alkalosis, and hypertension has been highlighted in case reports. However, presentation with lower gastrointestinal perforation is not known. We report the case of a 70-year-old male patient with severe hypokalaemia, metabolic alkalosis, hypertension, and colonic perforation as manifestations of an ACTH-secreting small cell lung carcinoma. Ectopic ACTH syndrome should be kept in mind as a cause of hypokalaemia, hypertension, and intestinal perforation in patients with lung carcinoma.
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Affiliation(s)
- Tezcan Kaya
- Assistant Professor, Department of Internal Medicine, Sakarya University Faculty of Medicine , Sakarya, Turkey
| | - Cengiz Karacaer
- Medical Doctor, Internal Medicine Specialist, Department of Internal Medicine, Sakarya University Training and Research Hospital , Sakarya, Turkey
| | - Seyyid Bilal Açikgöz
- Medical Doctor, Research Assistant, Department of Internal Medicine, Sakarya University Faculty of Medicine , Sakarya, Turkey
| | - Yusuf Aydemir
- Assistant Professor, Department of Chest Diseases, Sakarya University Faculty of Medicine , Sakarya, Turkey
| | - Ali Tamer
- Professor, Department of Internal Medicine, Sakarya University Faculty of Medicine , Sakarya, Turkey
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Hara T, Akutsu H, Yamamoto T, Ishikawa E, Matsuda M, Matsumura A. Cushing's disease presenting with gastrointestinal perforation: a case report. Endocrinol Diabetes Metab Case Rep 2013; 2013:130064. [PMID: 24616779 PMCID: PMC3922247 DOI: 10.1530/edm-13-0064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/30/2013] [Indexed: 11/08/2022] Open
Abstract
Gastrointestinal perforation is a complication associated with steroid therapy or hypercortisolism, but it is rarely observed in patients with Cushing's disease in clinical practice, and only one case has been reported as a presenting symptom. Herein, we report a rare case of Cushing's disease in which a patient presented with gastrointestinal perforation as a symptom. A 79-year-old man complained of discomfort in the lower abdomen for 6 months. Based on the endocrinological and gastroenterological examinations, he was diagnosed with Cushing's disease with a perforation of the descending colon. After consultation with a gastroenterological surgeon, it was decided that colonic perforation could be conservatively observed without any oral intake and treated with parenteral administration of antibiotics because of the mild systemic inflammation and lack of abdominal guarding. Despite the marked elevated levels of serum cortisol, oral medication was not an option because of colonic perforation. Therefore, the patient was submitted to endonasal adenomectomy to normalize the levels of serum cortisol. Subsequently, a colostomy was successfully performed. Despite its rarity, physicians should be aware that gastrointestinal perforation may be associated with hypercortisolism, especially in elderly patients, and immediate diagnosis and treatment of this life-threatening condition are essential. If a perforation can be conservatively observed, endonasal adenomectomy prior to laparotomy is an alternative treatment option for hypercortisolism.
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Affiliation(s)
- Takuma Hara
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Hiroyoshi Akutsu
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Masahide Matsuda
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
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