THE MULTIFARIOUS CUSHING'S - LESSONS FROM A CASE SERIES.

Endogenous Cushing's syndrome is rare, with an incidence of 0.7-2.4 per a million people a year. Clinical presentation of Cushing syndrome can be pleomorphic, and establishing diagnosis can be difficult. Early recognition and rapid control of hypercortisolaemia are necessary to decrease morbidity and mortality in these patients. We report a series of 6 endogenous Cushing's syndromes of different etiologies (4 Cushing's disease and 2 adrenal Cushing's syndrome) assessed in our endocrine department over a decade (2009-2019). In order to highlight the diversity of clinical forms, diagnostic tools and specific management of this condition we labelled each case suggestively: the typical Cushing's disease, the Pseudo Cushing's, the elusive Cushing's disease, the mild autonomous cortisol hypersecretion, Cushing's syndrome in pregnancy and Cushing's disease with thromboembolism. We discussed their particularities which were revelatory for the diagnosis, such as dermatologic, cardiovascular, musculoskeletal, neuropsychiatric, or reproductive signs, reviewing literature for each manifestation. We also discuss the commonalities and differences in laboratory and imagistic findings. Therapeutic approach can also differ with respect to the particular condition of each patient and the multiple choices of therapy will be reviewed.

Adrenal and pituitary incidentalomas in a case of Cushing's syndrome.

Cushing's syndrome is a pathological condition where surgery may be lifesaving. The proper diagnosis depends upon the hormonal pattern of the patient, various dynamic tests and imagistic investigations. We report a case of a patient with Cushing's syndrome, with bilateral adrenal tumors and a pituitary microadenoma. She presented increased levels of basal cortisol, unsuppressed during a low and a high dose Dexamethasone test. She underwent right laparoscopic adrenalectomy and developed acute adrenal insufficiency. Two years after the intervention, she still requires adrenal substitution therapy. Acute adrenal crisis is a serious complication of adrenal surgery, with high mortality if unrecognized.

Pituitary incidentalomas--how often is too often?

INTRODUCTION: Clinical nonfunctional pituitary microadenomas, also known as incidentalomas are accidental observations made due to the application of high resolution imaging techniques as computed tomography or magnetic resonance. There are no standards regarding the follow-up of these tumors and taking into account their increased frequency among general population (during the last years they were based on the high performances of the imaging methods), we decided to study their dimensions and their evolution over time. We have also analysed their behavior with respect to their endocrine phenotype and the minimum period of time needed for the repetition of the imagistic procedure. AIM: To observe the natural evolution of tumors' dimensions in a group of patients, diagnosed with nonfunctional pituitary microadenomas based upon hormonal measurements and computed tomography scan. METHOD: There is a retrospective observational study on 149 patients hospitalized in our Clinic between 1994 and 2006. Initially, all the pituitary hormones and the computed tomography were performed. Only nonfunctional microadenomas were included (the maximum diameter 11 mm). 69 patients were examined for a long period of time--29.75 +/- 24.79 months by CT scan and secretory profile, repeated at different periods of time. RESULTS: At the end of 29.75 months, the aspect of microadenoma was still present, without any statistically significant changes of the diameter. One of the cases became macroadenoma and another proved to be a microprolactinoma. Only 5 cases of all 149 presented a double lesion. No case of pituitary apoplexy was registered. These observations lead to the conclusion that it is not necessary to repeat the computed tomography scan sooner than 2 years once the diagnosis ofincidentaloma was established.

Autoimmune thyroid disease--a continuous spectrum.

AIM: to present a case report revealing a variant of natural history of autoimmune thyroid disease. CASE REPORT: I.F., a 39 years old woman, had a previous medical history of Graves' disease treated with antithyroid drugs (ATD). After 1 year of treatment, the remission was confirmed one and two years after ATD withdrawal. Twenty years after the initial hyperthyroidism, spontaneous subclinical hypothyroidism was diagnosed. The patient presented both anti TSH-receptor (TSH-R) antibodies (Ab), antithyroperoxidase (TPO) and antithyroglobulin (antiTgl) antibodies in elevated titres. CONCLUSION: Because of the shift from hyperthyroidism to euthyroidism or to spontaneous hypothyroidism, Graves' disease patients demand a strict follow-up after ATD therapy. It seems that there is an effect of TPOAb on thyroid destruction.