Adrenal Insufficiency Secondary to Septic Shock in a Male Patient with Iatrogenic Cushing's Syndrome: 2 sides of the Same Coin?

Abstract

Cushing's syndrome causes increased morbidity and mortality due to cardiovascular and infectious diseases. Exogenous Cushing's syndrome can render the adrenal glands unable to cope with severe infections and may result in Addisonian crisis, which can be fatal if not properly diagnosed and treated. During hospitalization for disease exacerbation, a man on chronic glucocorticoid therapy for Crohn's disease and Cushingoid features developed polymicrobial septic shock together with hypotension that was unresponsive to fluids. On suspicion of relative adrenal insufficiency (cortisol levels were "inadequately" normal), intravenous hydrocortisone was started; norepinephrine was also required to normalize blood pressure. Following clinical improvement, oral cortisone acetate was started. On discharge, he was instructed on how to manage stressful events by increasing oral glucocorticoid treatment or starting a parenteral formulation, if required. Chronic glucocorticoid therapy can cause severe side-effects; in addition, hypoadrenalism can occur in critical illnesses (eg, severe infections). Prompt recognition and proper therapy of this condition can be life-saving.

Keywords: Iatrogenic Cushing’s disease; adrenal insufficiency; septic shock.

Figure 1.

Dorsal magnetic resonance imaging showing vertebral fractures of T7, T10, and T11. The T7 body is reduced in height, with anterior wedge deformation and irregularities mostly of the upper somatic part, resulting from the fracture, which extends posteriorly up to the peduncle isthmus and to the postero-superior edge, which partially protrudes into the endocanalar space. Hyperintensity on signal short time sequence is due to edema from a recent trabecular microfracture (arrow). The T10 and, to a lesser extent, T11 bodies are reduced in height, with anterior wedge deformation.