Use of Continuous Etomidate Infusion to Rapidly Correct Hypercortisolism in a Patient With Disseminated Nocardiosis

Abstract

Cushing's syndrome (CS) is an immunocompromised state characterized by impaired cellular and adaptive immunity due to hypercortisolism. This imbalance in the immune system leads to a high risk of opportunistic infections which can potentially prove fatal. In such patients, mortality can be reduced with early diagnosis and effective management of the underlying hypercortisolism. In this case report, we describe how prompt reduction of cortisol levels using a low dose continuous etomidate infusion was pivotal in effective treatment of an opportunistic infection, disseminated nocardiosis, in a 29-year-old female with Cushing's syndrome. We also discuss how treatment with antibiotics including empiric therapy with Imipenem and sulfamethoxazole/trimethoprim (SMX/TMP) and definite therapy as per susceptibility testing, with amikacin, SMX/TMP, and doxycycline helped to prevent adverse outcomes. Through this case, we aim to emphasize that infiltrates or cavitary lesions on the computed tomography (CT) scan of the chest in a patient with Cushing's syndrome should raise concern for nocardiosis, and prompt management with antibiotics should be initiated. Similarly, disseminated nocardiosis should always raise concern for possible immune deficiency states like Cushing's syndrome. Our case is unique in detailing the significance of using etomidate to acutely lower cortisol levels in a patient with endogenous CS and widespread invasive opportunistic infection. The pharmacology aspects of the Etomidate, in this case, have been published in the Journal of Pharmacy Practice and cited appropriately in this article.

Keywords: cavitary lung lesions; cushing's syndrome; disseminated nocardiosis; etomidate; hypercortisolism.

Figure 1. Transverse view of CT scan of chest without contrast showing a right lung cavitary lesion with thickened walls measuring 3.3 cm x 3.7 cm.

Figure 2. MRI scan of the brain, coronal section, showing lesion in the left anterior lentiform nucleus measuring 8.8 mm x 8 mm with surrounding edema.

Figure 3. Transverse view of CT scan of the abdomen without contrast showing a peritoneal nodule measuring 1.2 cm x 1.7 cm.