Endo Case Challenge: A 36-Year-Old Has Cramping, Lung Issues and Can’t Lose Weight

Romesh Khardori, MD, PhD


March 31, 2022

In this patient, gain from surgical excision extended to better achievement of glycemic control and near resolution of hypertension. He was normotensive on 10 mg daily of ramipril. Previously, he required four agents and his blood pressure control was suboptimal. At higher concentrations of cortisol, activity spills over to mineralocorticoid receptor, thus mimicking a primary mineralocorticoid excess state.

Failure to lose weight and worsening of glycemic control should prompt search for precipitating factors beyond consideration of dietary indiscretion or noncompliance with therapy. When worsening of hypertension and emergence/persistence of hypokalemia is noticed, consider glucocorticoid/mineralocorticoid and catecholamine excess states. Although hyperthyroidism causes worsening of glycemic control, weight gain is less common.

Glucocorticoid excess state (more so in hyperglycemic patients with diabetes) is a perfect setup for superadded bacterial or fungal infections, often with fatal outcome.[3] Early diagnosis and treatment is life-saving.

A single-institution review of ACTH-secreting bronchial carcinoid tumor reinforced early detection and aggressive management to reduce consequences of chronic hypercortisolism and reduce risk for metastases.[4] Mifepristone, a glucocorticoid/progesterone receptor antagonist, was approved for the management of hyperglycemia in patients with Cushing syndrome. However, it may worsen hypertension and hypokalemia.


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