Rhode Island Chapter Abstracts

Title: Three Concurrent Opportunistic Infections in a Patient with Endogenous Cushing''s Syndrome. Abstract Text: Introduction: Hypercortisolemia secondary to endogenous Cushing's syndrome or to exogenous corticosteroid treatment, has long been associated with opportunistic infections. Case Presentation: A 55-year-old male with a history of alcohol and cocaine abuse was admitted to the hospital for evaluation of newly diagnosed hypertension and labs showing hyperglycemia, hypokalemia and metabolic alkalosis. He was diagnosed with Cushing''s syndrome based on an ACTH of 348 pg/ml (10-60 pg/ml) and a Cortisol of 87.4 mcg/dl (4.3-22.4 mcg/dl). MRI of the brain revealed a pituitary microadenoma, but dexamethasone suppression test was negative at both low and high doses, suggesting ectopic ACTH secretion. During hospitalization, the patient developed ground glass infiltrates, several cavitary lesions, and a pleural effusion that grew Nocardia. He was discharged on Bactrim DS to complete a 6-month course, and was to undergo PET scan and inferior petrosal sinus sampling to identify the source of elevated ACTH. For unclear reasons, these studies were not performed. Patient was readmitted to the hospital after five weeks with hypoglycemia and respiratory symptoms. He was found to have new extensive multifocal consolidations on CT chest, and Vancomycin, Piperacillin-Tazobactam and Azithromycin were added to Bactrim DS. On D2, the patient was transferred to the ICU for impending respiratory failure. Antibiotics were changed to Linezolid, Meropenem and Azithromycin. Bronchoscopy with BAL was performed. The patient developed AKI, ARDS and septic shock. BAL showed filamentous fungi so Voriconazole was added and Meropenem was changed to Imipenem for better coverage of Nocardia. The patient passed away on hospital D6 due to unremitting shock and hypoxemia. BAL culture was positive for Nocardia Nova, Aspergillus Fumigatus, and MAI. Discussion: We present a case of endogenous Cushing''s syndrome with a dexamethasone suppression testing suggestive of ectopic ACTH secretion. The patient''s clinical course was complicated by three different concurrent opportunistic infections; an uncommon but not unique presentation in this disease. It is likely that Nocardia failed to respond to therapy due to persistent hypercortisolemia and subsequent severe immunosuppression. A robust literature exists demonstrating the adverse consequences of hypercortisolemia on myriad components of the immune system, and yet the "safe" dose of exogenous steroids remains open to debate. The clinical scenario is often confounded by the patients'' underlying disease or diseases, the severity of the disease, and the use of concurrent immunosuppressive therapies. We will review this topic and the clinical …