Cushing’s syndrome (CS) secondary to ectopic adrenocorticotrophic hormone (ACTH)-producing prostate cancer is rare with less than 50 cases reported. The diagnosis can be challenging due to atypical and variable clinical presentations of this uncommon source of ectopic ACTH secretion. We report a case of Cushing’s syndrome secondary to prostate adenocarcinoma who presented with symptoms of severe hypercortisolism with recurrent hypokalaemia, limb oedema, limb weakness, and sepsis. He presented with severe hypokalaemia and metabolic alkalosis (potassium 2.5 mmol/L and bicarbonate 36 mmol/L), with elevated 8 am cortisol 1229 nmol/L. ACTH-dependent Cushing’s syndrome was diagnosed with inappropriately normal ACTH 57.4 ng/L, significantly elevated 24-hour urine free cortisol and unsuppressed cortisol after 1 mg low-dose, 2-day low-dose, and 8 mg high-dose dexamethasone suppression tests. 68Ga-DOTANOC PET/CT showed an increase in DOTANOC avidity in the prostate gland, and his prostate biopsy specimen was stained positive for ACTH and markers for neuroendocrine differentiation. He was started on ketoconazole, which was switched to IV octreotide in view of liver dysfunction from hepatic metastases. He eventually succumbed to the disease after 3 months of his diagnosis. It is imperative to recognize prostate carcinoma as a source of ectopic ACTH secretion as it is associated with poor clinical outcomes, and the diagnosis can be missed due to atypical clinical presentations.
Rationale: Symptomatic hypocalcaemia is uncommon, occurring in <2% of patients with malignancy. Osteoblastic bone metastasis as a cause of hypocalcaemia is rare and not reported in bladder cancer. Patient concerns: We report a case of refractory hypocalcaemia in a patient with bladder cancer with extensive osteoblastic bone metastases. A 64-year-old male with a history of signet ring bladder carcinoma with osteoblastic bone metastases presented with severe hypocalcaemia with corrected calcium of 1.64 (2.09–2.46) mmol/L as well as hypomagnesemia and hypophosphatemia. He was previously treated with chemotherapy and immunotherapy. Denosumab was also initiated for the prevention of skeletal-related events. Diagnoses: Additional investigations showed significantly elevated bone formation markers N-terminal propeptide of type I procollagen and alkaline phosphatase. Chest radiography and computed tomography scan also demonstrated extensive areas of sclerotic bone lesions suggestive of osteoblastic bone metastases. He was diagnosed with severe hypocalcaemia secondary to osteoblastic bone metastases and partly to denosumab, vitamin D deficiency, and hypomagnesemia. Interventions: He was treated aggressively with calcium and vitamin D replacement. Outcomes: Despite prolonged intravenous calcium replacement and high doses of oral calcium, cholecalciferol, and calcitriol replacement, he had persistent hypocalcaemia with calcium levels ranging from 1.8 to 1.9 mmol/L. He died 4 months after his admission. Lessons: Osteoblastic bone metastases lead to an increased influx of calcium and phosphate into the bone leading to hypocalcaemia and should be considered as a differential in severe and refractory hypocalcaemia. It is rare and has not been described in bladder cancer. Precaution should be taken upon the initiation of antiresorptive in patients with osteoblastic bone metastases.
Summary We report a case of subacute thyroiditis in a 40-year-old female who initially presented with painful thyroid nodules without clinical and biochemical evidence of hyperthyroidism. Thyroid ultrasound was done to evaluate the thyroid nodules and fine-needle aspiration (FNA) was performed in view of the suspicious features. As the FNA showed a follicular lesion of undetermined significance or atypia of undetermined significance (FLUS/AUS, Bethesda III), she was advised for surgical excision. She was subsequently diagnosed with subacute thyroiditis based on her clinical symptoms, biochemical evidence of hyperthyroidism, raised erythrocyte sedimentation rate (ESR) as well as low uptake on thyroid scintigraphy. The thyroid lesions disappeared after symptomatic treatment. It is important to recognise that subacute thyroiditis can present with painful thyroid lesions with ultrasound features similar to suspicious thyroid nodules which can resolve with the resolution of the thyroiditis. Learning points Subacute thyroiditis can present with atypical features such as the absence of pain, normal erythrocyte sedimentation rate or absence of hyperthyroidism. In subacute thyroiditis, ultrasound findings are commonly described as focal or multifocal lesions with poorly defined and heterogeneous and hypoechoic echogenicity which can be misdiagnosed as malignancy. Thyroid lesions can resolve with the resolution of thyroiditis with or without symptomatic treatment.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.