Sudden Respiratory Failure in a Patient with Cushing`s Syndrome

A 79 year-old patient with prostate cancer related Cushing's syndrome was referred to ICU for acute respiratory distress occurring two days after introduction of mifepristone. Pneumocystis jirovecii pneumonia was diagnosed. Despite anti pneumocystis therapy and supportive treatment, the patient died of multiple organ failure. The relationship between mifepristone and Cushing's syndrome and potential implications are discussed. Cushing's syndrome is a classical but rare disease resulting from exposure to excessive concentrations of glucocorticoid. When surgery is not feasible medical therapy should be discussed. A 79 year-old man was admitted to intensive care unit for acute respiratory distress. He had been treated for prostate cancer for 12 years, with radiotherapy and hormonotherapy. The last prostate-specific antigen (PSA) level was (0, 24 ng/ml) while pelvis MRI disclosed irregular prostate consistent with radiotherapy after-effects without any sign of recurrence of malignancy. He was referred 3 months before to the general ward because of depression, severe systemic hypertension, hypokalaemia and diabetes mellitus. Endogenous hypercortisolism was diagnosed. Static and dynamic analysis: (plasma cortisol level at 8 am : 1564 nmol/l (normal<200 nmol/l), 24h urinary free cortisol excretion: 20200 nmol/24h (normal <270 nmol/24h), no suppression of plasma cortisol with low dose of dexamethasone, adrenocorticotropic hormone (ACTH) : 145 ng/l.(normal<50 ng/l)) were in favour of an ACTH dependent Cushing's syndrome. Considering normal pituitary MRI, final diagnosis was paraneoplastic Cushing's syndrome. CT scan imaging of the thorax (Fig. 1), abdomen and pelvis disclosed bilateral adrenal hyperplasia but did not show any thoracic or pancreatic tumours which are the most common tumours responsible for ectopic ACTH secretion.