Massive Thoracoabdominal Aortic Thrombosis in a Patient with Iatrogenic Cushing Syndrome

Massive thoracoabdominal aortic thrombosis is a rare finding in patients with iatrogenic Cushing syndrome in the absence of any coagulation abnormality. It frequently represents an urgent surgical situation. We report the case of an 82-year-old woman with massive aortic thrombosis secondary to iatrogenic Cushing syndrome. A follow-up computed tomography scan showed a decreased amount of thrombus in the aorta after anticoagulation therapy alone.

Kaposi's Sarcoma in a Patient with Iatrogenic Cushing's Syndrome / 대한피부과학회지

Kaposi's sarcoma (KS) is a multifocal proliferative vascular tumor involving cutaneous and extra-cutaneous tissues. KS has been reported in patients treated with immunosuppressive agents for autoimmune diseases. However, KS has rarely been reported in patients with iatrogenic Cushing's syndrome. A 77-year-old woman was evaluated with multiple asymptomatic violaceous nodules and plaques on both lower legs. She had been diagnosed with iatrogenic Cushing's syndrome and had been treated with low-dose corticosteroid replacement therapy for >10 years. A histopathologic study showed extensive vascular proliferation in the dermis with spindle-shaped cells. Immunohistochemical staining for CD31, CD34, human herpesvirus (HHV)-8, and D2-40 was positive. We hereby report a case of KS in a patient with iatrogenic Cushing's syndrome.

Subcutaneous Candidal Abscess in the Patient with Iatrogenic Cushing Syndrome / 대한의진균학회지

Candida albicans is a dimorphic yeast which is responsible for 70 percent to 80 percent of all candidial infection, and is the most common cause of superficial and systemic candidiasis. Invasive candidiasis occurs under certain circumstances such as immunosuppression, prolonged hospitalization, and previous antibiotics use. We report a case of candidiasis with a unusual presentation of subcutaneous abscess. A 54 year-old woman came to our clinic with painful erythematous swelling plaques and nodules on the face and arms. She was hospitalized with generalized edema and weakness of both leg. She had a history of herbal medication for 1 year and was finally diagnosed with iatrogenic Cushing syndrome in department of the endocrinology. Biopsy of the lesion revealed chronic inflammation in dermis and subcutis and budding yeasts with pseudohyphae were shown in Gomoris Methenamine silver stain. And Candida albicans was identified by fungus culture.

Suspected Case of Iatrogenic Cushing Syndrome Due to Topical Steroid / 대한피부과학회지

Chronic exogenous steroid therapy can result in hypothalamic-pituitary-adrenal axis dysfunction; this usually results from systemic steroid therapy, and is rarely associated with topical steroid therapy. We report a case of suspected iatrogenic Cushing syndrome that developed after the treatment of annular pustular psoriasis. The patient applied clobetasol-17-propionate cream (Betabate(R)) 15~30 g daily, for 4 months, without a dermatologist's prescription. After 4 months of application, the following symptoms developed; a moon face; facial flushing; hypertrichosis; central obesity; purple striae; and multiple erythematous scaly annular patches. The development of Cushing syndrome from exogenous corticosteroid treatment was supported by the typical clinical manifestations and the low basal state of the blood cortisol level, which was perhaps due to secondary suppression of the hypothalamic pituitary-adrenal axis. Steroid-containing drugs, especially during childhood, should be used with caution and monitored carefully.

A case of Human Herpesvirus 8 Related Kaposi's Sarcoma in a Patient with Iatrogenic Cushing's Syndrome / 대한피부과학회지

Kaposi's sarcoma(KS) is a multicentric proliferative vascular tumor involving cutaneous and visceral tissues. KS was one of the first recognized manifestations of AIDS. A 71-year-old woman was seen with multiple violaceous nodules and painful erythematous cellulitis-like swelling on both lower legs. Easy bruising and senile purpura was also noted on her forearms. She had been suffered from lower back pain for 7 years, and had been treated with corticosteroids. Clinical picture and hormonal study revealed that she had iatrogenic Cushing's syndrome. The histopathologic study from skin lesion showed abnormally proliferated and dilated vessels, vascular slits, spindle shaped cells in the entire dermis. Human herpesvirus 8(HHV-8) was detected by nested polymerase chain reaction(PCR) using the paraffin-embedded skin tissue. She received localized radiotherapy(50 Gray) to both lower legs with favorable response. But five months later, her skin lesions had recurred and progressed into more aggressive pattern mainly on her left lower leg. We report a rare case of human herpesvirus 8 related KS in iatrogenic Cushing's syndrome.

Usefullness of Urinary Free Cortisol Measurement in Diagnosis of Iatrogenic Cushing Syndrome / 대한내분비학회지

BACKGROUND: Although insulin induced hypoglycemia test is a standard diagnostic method in assessment of hypothalamo-pituitary-adrenal axis, rapid ACTH stimulation test using 250microgram has been used as a first line diagnostic test especially in secondary adrenal insufficiency due to iatrogenic Cushing syndrome because it is easy and safe. However, it was suggested that a maximal cortisol response can be achieved with a much lower ACTH dose and 1microgram ACTH enhances the sensitivity without decreasing specificity of test. Also recently, there was a report that midnight to morning urine cortisol increment is more accurate, noninvasive method can be used for measurement of hypothalmo-pituitary-adrenal axis. In this study, we compared the 1microgram ACTH stimulation test with midnight to morning urinary free cortisol increment in secondary adrenal insufficiency due to iatrogenic Cushing syndrome to study the agreement of two test and accuracy of increment of urinary free cortisol in diagnosis of adrenal insufficiency. METHODS: Double voided urine sample were collected at midnight and 8 A.M. in 12 patients who have Cushing-like feature and history of taking glucocorticoids and in 12 normal controls. Urinary free cortisol was measured and cortisol increment was defined as the morning urine free cortisol minus the midnight urine free cortisol. The 1microgram ACTH stimulation test was performed in 12 iatrogenic Cushing syndrome patients at the same day and compard with the result of cortisol increment. RESULTS: Using the results of 12 controls, normal urine free cortisol increment was defined as greater than 165.5nmol/L(6.0microgram/dL). Subnormal cortisol response in 1microgram ACTH stimulation test was noted in 8 out of 12 patients group and urinary free cortisol increment was not observed in 7 out of 8 subnormal response group. Normal cortisol response in 1microgram ACTH stimulation test was noted in 4 out of 12 patients group and urinary free cortisol increment was observed in 3 out of 4 normal response group. So 83% of concordance rate between 1microgram ACTH stimulation test and urine free cortisol increment was recorded. CONCLUSION: Urinary free cortisol increment has high concordance rate with 1microgram ACTH stimulation test and simple, easy test in diagnosing secondary adrenal insufficiency due to iatrogenic Cushing syndrome. Further study including more patients will be helpful to know the adequacy and reliability of test in evaluation of hypothalamo-pituitary-adrenal axis.

A Case of Primary Cutaneous Cryptococcosis in a Patient with Iatrogenic Cushing's Syndrome / 대한의진균학회지

We presented here a case of the primary cutaneous cryptococcosis in a patient with iatrogenic Cushing's syndrome. The patient was 72-year-old female and showed painful shallow ulcer with pus discharge on the left forearm. She had been receiving systemic corticosteroids without doctor's prescription for 20 years. Laboratory findings revealed impaired cell mediated immunity, decreased serum and urine cortisol, and ACTH. A biopsy specimen showed granulomatous reaction consisting of lymphohistiocytes, multinucleated giant cell, and many spores with thick capsules. A tissue and pus culture of the lesion on Sabouraud's media at 37 degrees C showed moist smooth, mucoid creamy colored colonies 3 days later and revealed encapsulated yeast cells in the India ink preparations. The patient was successfully treated with oral itaconazole and fluconazole without side effects.