[Cushing syndrome with life-threatening infectious complications]

During treatment of phlegmon of the face, which involved the cornea, a 54-year-old man was transferred to the medical ward because of dyspnoea of rapid onset. He was known to have arterial hypertension with heart failure and diabetes mellitus, and to have sustained a fracture of the femur after minimal trauma. He had central cyanosis, ankle oedema, cushingoid appearance and ecchymoses. Loud rales ware heard over both lungs. Body temperature was 38.9 degrees C.

Laboratory tests indicated acute inflammation and he had signs of global respiratory failure. X-ray of the thorax showed cardiomegaly and an infiltrate in the right lung. The ECG indicated an old myocardial infarct and left heart strain.

Mechanical ventilation with intubation became necessary because of deteriorating respiratory function. Broad-spectrum antibiotics and antibiotics against suspected fungal pneumonia were administered; he was extubated after 28 days. Cortisol excretion of more than 3300 micrograms/24 h and failure of cortisol suppression after 1 mg dexamethasone were diagnostic of hypercortisolism. Other endocrine tests revealed an adrenal lesion, shown by computed tomography to be an adrenal tumour, 3 cm in diameter. It was excised and histologically proved to be an adenoma.

Nowadays infectious complications due to cortisol-associated immunosuppression are rare in Cushing disease, because of its early recognition and treatment. But hypercortisolism should be considered in patients with severe and prolonged infections.