Abstract 95: Cushings: The tale of a great mimicker and its conundrums

Background: Cushing's syndrome is a rare endocrine disorder comprising of large group of signs and symptoms resulting from chronic exposure to state of endogenous hypercortisolemia or exogenous steroids. It is a gamut of clinical manifestations with varying presentation and indecisive diagnosis. Aim: We hereby present a case of 28-year-male with signs and symptoms of florid and rapid onset hypercortisolemia of 1 year duration. Objectives and Results/Case Details: Case was referred from psychiatry for weight gain. Clinical history and profound proteo-catabolic signs pointed towards rapid onset cushings. On evaluation hypercortisolism was non-suppressible by 1 mg dexamethasone (DST) and had high ACTH suggesting ectopic ACTH syndrome or pituitary origin. He had a history of watery diarrhea, recalcitrant hypokalemia, multiple hyper-pigmented acne, and striae with secondary superficial mycosis which compelled us to rule out ectopic, but CT chest & abdomen were inconclusive. MRI pituitary showed 4 mm adenoma, cortisol was suppressed following 8 mg DST. He underwent Trans-sphenoidal surgery (TSS), following which cortisol levels normalized within 1week with regression of symptoms. Conclusion: Throughout the course, several diagnoses were entertained like perceptive disorder due to depression and bizarre paresthesia (hypocalcemia), carcinoid syndrome secondary to diarrhea and dys-electrolytemia, ectopic ACTH source due to clinical profile, coincidental lung lesion, but ultimately proven as ACTH producing pituitary tumor out of the blue. Use of a more pragmatic approach makes this case a challenging one.