Profound Proximal Muscle Weakness Research Articles

FRI200 Severe Cushing Syndrome Due To An ACTH-producing Pheochromocytoma

Abstract Disclosure: G.A. Stamatiades: None. A. Bikas: None. H.J. Shah: None. K. Wong: None. A. Vaidya: None. M. Nehs: None. S.S. Basaria: None. Background: Pheochromocytomas are rare catecholamine-secreting tumors that arise from sympathetic adrenomedullary chromaffin tissue. Rarely, pheochromocytomas co-secrete ACTH and patients present with Cushing syndrome. Due to its rarity, clinicians may not consider this etiology of Cushing syndrome. We report a case of a man with ACTH-producing pheochromocytoma in whom methodic systematic approach led to its diagnosis and successful treatment. Clinical Case: A 48-year-old man presented with altered mental status. His family confirmed depressed mood, paucity of thought, and occasional blank stares. The patient was diagnosed with type-2 diabetes mellitus and hypertension 3 months ago, which were not controlled despite being on multiple anti-hypertensives and anti-diabetic agents. His EEG, head CT, and brain MRI were normal. On admission, his laboratory tests were notable for hypokalemia (3.0 mmol/L, n<5.3 mmol/L) and metabolic alkalosis (HCO3 33 mmol/L, n<32 mmol/L). Physical examination showed facial plethora, multiple ecchymoses and profound proximal muscle weakness. CT scan of the abdomen showed a 3.4 cm left adrenal nodule with a density of 33 Hounsfield units and a 73% absolute washout. The right adrenal gland was hyperplastic. Plasma and urinary metanephrines were significantly elevated (plasma metanephrines 1.6 nmol/l, n < 0.50 nmol/l, urinary metanephrines 1,685 mcg/24h, n <646 mcg/24h). Midnight salivary cortisol was 11,500 ng/dl (n<100 ng/dl) and 24h urinary free cortisol was 13,099 mcg/24h (n < 45 mcg/24h). ACTH was 450 pg/ml (n<63pg/ml) with a serum cortisol of 93 ug/dl (n<18.4 ug/dl). His serum cortisol after 8 mg Dexamethasone Suppression test was 100 ug/dl. DOTATATE PET CT scan showed uptake in the left adrenal nodule. The workup was suggestive of left-sided pheochromocytoma producing ectopic ACTH. The patient underwent laparoscopic left adrenalectomy. Postoperative ACTH was undetectable, indicating surgical cure. His blood pressure and plasma glucose gradually improved and remained normal after discontinuation of all medications. Surgical pathology was consistent with pheochromocytoma with positive staining for ACTH, confirming the diagnosis of ACTH-producing pheochromocytoma. He was discharged home after successful rehabilitation. Clinical Lessons: Pheochromocytomas are a rare cause of ectopic ACTH production, resulting in clinical Cushing syndrome. Imaging of the contralateral adrenal gland provides a valuable clue in making the diagnosis of ectopic ACTH production (as the gland is enlarged rather than atrophic). Reference: (1) Elliott PF, Berhane T, Ragnarsson O, Falhammar H. Ectopic ACTH- and/or CRH-Producing Pheochromocytomas. J Clin Endocrinol Metab. 2021 Jan 23;106(2):598-608. doi: 10.1210/clinem/dgaa488. PMID: 32710791. Presentation: Friday, June 16, 2023

SAT328 Severe Exogenous Cushing Syndrome Caused By A Potent Steroid Concealed In Arthritis Supplement

Abstract Disclosure: S. Maraqa: None. L. Bushnaq: None. R. Singh, PhD: None. N. Genere: None. Cushing syndrome (CS) is a rare disorder caused by excessive systemic glucocorticoids and associated with increased mortality and worsening quality of life. CS most commonly occurs from exogenous glucocorticoid use, while Cushing disease causes most of endogenous cases. Here, we present a case of a 64-year-old woman with rapidly progressive CS due to an over-the-counter (OTC) arthritis supplement with unlisted dexamethasone. A 64-year-old woman with reported CS who was evaluated in our Endocrinology center after she moved to the United States. She was previously diagnosed with pituitary CS in Mexico following a 6 months history of rapid 50-pound weight gain, profound proximal muscle weakness requiring assistive device, and unprovoked vertebral fractures; laboratory evaluation found elevated 24-hour urinary cortisol 272 mcg/24h, 1mg dexamethasone suppression test total cortisol 5.6 mcg/dl (< 1.8), and adrenocorticotropic hormone (ACTH) 16 pg/mL. Pituitary MRI was unremarkable. Past medical history included primary hypothyroidism and hypertension. Physical exam was notable for blood pressure 160/108 mmHg, heart rate 96, BMI 33 kg/m², moon face, supraclavicular fat pads, central obesity, skin bruises, and proximal muscle weakness. Unexpectedly, re-evaluation showed undetectable serum ACTH and cortisol. A thorough review of medications identified no recent exposure to glucocorticoids. However, a synthetic glucocorticoid screen showed markedly elevated serum dexamethasone concentration. Follow-up discussion revealed that she had started an arthritis supplement “Artri-King” 6 months prior to these symptoms. We collaborated with Mayo Clinic Labs to evaluate dexamethasone contents in this drug; each tablet was found to contain 0.9 mg of dexamethasone, which was unreported in the ingredient list. This supplement was stopped, and the patient was started on physiologic hydrocortisone. Two months later, AM cortisol was 5.6 mcg/dL and ACTH 23 pg/ml. Eight months later, she continues to have adrenal insufficiency but has had a substantial clinical improvement.Exogenous CS is readily diagnosed in patients taking prescribed glucocorticoids; however, diagnosis can be more challenging in cases where the presence of glucocorticoids is concealed. The US Food and Drug Administration follows more limited regulatory guidelines for dietary supplements compared to prescribed drugs. A study by Tucker.et.al. reported that 20% of dietary supplements have unapproved ingredients.1 This is especially concerning, considering that over half of the US population admits to taking dietary supplements.2 On April 2022, the FDA published a public notice for “Artri-King”, declaring the presence of unlisted dexamethasone.3 Should such agents prove to be the culprit of CS, they must be tapered off gradually or in the presence of physiologic hydrocortisone to avoid the risk of adrenal crisis. Presentation: Saturday, June 17, 2023

SAT-118 Rapid Decompensation from Complications of Severe Hypercortisolism in an Unusual Presentation of an Ectopic ACTH-Secreting Neuroendocrine Tumor

Background: Ectopic Cushing’s syndrome from an ACTH-secreting neuroendocrine tumor (NET) is a rare condition whose onset and disease progression is often more aggressive than other forms of Cushing’s syndrome due to complications from severe hypercortisolism. Clinical Case: A 75-year old woman presented with profound proximal muscle weakness, severe hypokalemia, Cushingoid features, and biopsy-proven Candida esophagitis. Initial testing was consistent with ACTH-dependent Cushing syndrome: elevated 24 hour urinary cortisol excretion (1,310.54 mcg/24h; n <50 mcg/24h), abnormal 1 mg dexamethasone suppression test (68.3 ug/dL), and elevated ACTH level (200 pg/mL; n: 7.2–63.3 pg/mL). MRI was negative for a pituitary lesion but abdominal CT revealed an 8.8 cm liver mass with biopsy consistent with a well-differentiated neuroendocrine tumor, WHO Grade 2. Subsequent 68Ga-DOTATATE-PET/CT noted DOTATATE uptake in the liver lesion, a 0.9 cm right pulmonary nodule, and the pancreatic tail without CT correlate. Initially, the patient was prescribed mifepristone and spironolactone for hypokalemia. Given her NET of unknown primary, metastatic disease, and immunocompromised state due to hypercortisolism, the patient was not a candidate for surgical resection of her NET but was instead referred for bilateral adrenalectomy. However, she rapidly decompensated from complications of her hypercortisolism prior to surgery. Her weakness progressed to immobility, and she developed acute psychosis manifested as agitation and mutism. The patient was immediately admitted to the hospital where she developed new-onset atrial flutter and myelosuppression requiring multiple transfusions. She underwent urgent bilateral adrenalectomy, but despite surgery, her post-operative course was complicated by hypoxemic respiratory failure and shock. The patient shortly thereafter expired from pulseless electrical activity arrest. Conclusion: This atypical case of an ectopic ACTH-secreting NET highlights the life-threatening complications associated with severe hypercortisolism, including: opportunistic infection, severe metabolic abnormalities, psychosis, myopathy, and critical illness that can incite myelosuppression and unstable arrhythmias. These patients can quickly deteriorate and are at high risk for mortality. Early diagnosis and swift reversal of their hypercortisolism with bilateral adrenalectomy are oftentimes needed to prevent these potentially fatal complications.

Adolescent with Hypothyroidism Induced Rhabdomyolysis and Acute Kidney Injury

Objectives: Rhabdomyolysis is a potentially life-threatening syndrome. Hypothyroid patients may present with myopathy and mild elevation of CK levels; however, overt rhabdomyolysis is extremely rare, and few cases have been described. Hypothyroidism should be considered in patients presenting with renal impairment associated with rhabdomyolysis. Case report: A 24-year-old young man with accidently discovered hypothyrodism on admission presented with generalized myalgia, profound proximal muscle weakness of the bilateral lower extremities, anuria, vomiting and dark colored urine lasting for three days. Neurological examination revealed bilateral marked weakness and tenderness of muscles of both lower and upper extremities. Urine had dark red appearance and urinalysis showed blood reaction with dipstick test, but there were no erythrocytes on microscopic examination. Serum creatine phosphokinase and myoglobin levels were elevated. Thyroid stimulating hormone (TSH) levels were high, and Free Thyroxine (T4) and Triiodothyronine (T3) levels were low, renal function tests showed acute kidney injury. Other causes of rhabdomyolysis such as muscular trauma, drugs, toxins, infections, vigorous exercise, and electrolyte abnormalities were excluded. Hemodialysis was administered for five sessions. After L-thyroxine therapy, thyroid function tests normalized, muscle strength improved, serum muscle enzyme levels returned to normal levels, and renal function tests recovered. Conclusion: Hypothyroidism should be considered in patients presenting with renal impairment associated with rhabdomyolysis.

Rare Causes of Calcitriol-Mediated Hypercalcemia: A Case Report and Literature Review

Calcitriol-mediated hypercalcemia resulting from elevated extrarenal 25-hydroxyvitamin D-1alpha-hydroxylase (1alpha-hydroxylase) activity has not previously been described in giant cell polymyositis. We report an unusual case of hypercalcemia due to disseminated granulomatous disease in a 62-yr-old woman with profound proximal muscle weakness and weight loss. She was initially diagnosed with vitamin D deficiency myopathy with a low serum 25-hydroxyvitamin D; serum calcium at this time was low-normal. Vitamin D(3) 3000 IU daily was prescribed. One month later, blood work showed new hypercalcemia and hypercalciuria with normalized 25-hydroxyvitamin D. 1,25-dihydroxyvitamin D was high-normal, despite a suppressed PTH, undetectable PTHrP, and essentially normal renal function. Her hypercalcemia resolved, and her strength improved only after prednisone was added to bisphosphonate therapy. Two weeks later, she died from acute congestive heart failure. Autopsy revealed a disseminated giant cell myositis affecting skeletal, cardiac, and gastrointestinal smooth muscle. Immunohistochemistry localized 1alpha-hydroxylase to the inflammatory infiltrates in skeletal and cardiac muscle. A review of English publications in Medline and Embase, including a reference search of retrieved articles, revealed that calcitriol-mediated hypercalcemia has been described in over 30 conditions, most of which are granulomatous in nature, ranging from inflammatory conditions and foreign body exposures to infections and neoplasms. Hypercalcemia resulting from autonomous 1alpha-hydroxylase activity may be unmasked by low-dose vitamin D supplementation and should not be excluded from the differential diagnosis of nonparathyroid causes if the serum calcitriol is inappropriately normal, rather than frankly elevated.

Primary hepatic carcinoid tumor presenting as Cushing’s syndrome

Hepatic carcinoid tumors are very uncommon; most are clinically non-functional and very few present with the symptoms of carcinoid syndrome. ACTH-producing carcinoid tumors most commonly originate in the lung or thymus and present insidiously with bronchospasm and/or chest mass. Occasionally, ectopic ACTH syndromes have been reported in association with pancreatic islet cell tumors, medullary thyroid cancer, pheochromocytoma, small-cell lung carcinoma, and rarely, ovarian and prostate tumors. We report here a patient with an ectopic ACTH-secreting primary hepatic carcinoid tumor who presented with cushingoid appearance, profound proximal muscle weakness, severe lower extremity edema, and markedly elevated urinary free cortisol. ACTH levels were in the low normal range. A solitary vascular hepatic lesion was found on magnetic resonance imaging, which was isodense with the surrounding liver on octreotide scan and photopenic on an 18-fluorodeoxyglucose (18FDG)-positron emission tomography (PET) scan. Following surgical resection of the hepatic tumor, histopathology confirmed an ACTH-secreting neuroendocrine tumor (NET), the patient had complete resolution of hypercortisolemic symptoms and remains in remission, now 4 yr after hepatic tumor resection. This case reports the first ACTH-secreting primary hepatic NET presenting as ectopic Cushing's syndrome. Interesting aspects of this case include the presence of a pituitary incidentaloma, the low normal ACTH, and photopenia on 18FDG-PET imaging.

Inflammatory myositis complicating hypocomplementemic urticarial vasculitis despite on-going immunosuppression

We present a patient with previously diagnosed hypocomplementemic urticarial vasculitis syndrome, with skin, lung, and renal involvement, who presented with congestive cardiac failure. During the course of her hospitalization, she was also found to have profound proximal muscle weakness in both upper and lower limbs associated with raised creatinine kinase levels. A muscle biopsy was performed, which demonstrated evidence of an inflammatory myositis with vasculitis, which had returned despite on-going immunosuppression. This occurrence of a new autoimmune disease may well be an example of the "waste disposal" hypothesis.

Inflammatory myositis in systemic sclerosis: a South Australian perspective

AbstractBackground: Muscle atrophy and weakness occurs commonly in patients with systemic sclerosis, especially late in the course of the disease. However, profound proximal muscle weakness secondary to myositis is an infrequent finding.Aim: To determine the frequency and disease characteristics of patients with myositis in our cohort of systemic sclerosis patients.Methods: A retrospective case note review of the clinical course of all patients enrolled on the South Australian scleroderma register, a population‐based register of 374 living and 234 deceased patients with systemic sclerosis, last updated to the end of December 2002.Results: Twenty patients with myositis were identified, the majority with diffuse cutaneous systemic sclerosis and overlap syndromes. The calculated frequency of this complication was 3.3% in our population‐based cohort. All patients suffered profound proximal muscle weakness complicated by functional impairment. Other clinical features included weakness of cervical musculature (15%), dyspnoea (10%) and dysphagia (10%). Creatine kinase level was elevated in 80% of the patients, with the mean peak creatine kinase level of 1129 U/L. When further investigations were undertaken, 80% of patients demonstrated myopathic changes on electromyography and 92% of patients were found to have histological findings characteristic of an inflammatory process. Positive antinuclear antibodies were identified in all patients, including two with anti‐PM‐Scl autoantibodies.Conclusion: Myositis is an infrequent clinical feature in patients with systemic sclerosis. Profound proximal weakness in association with elevated creatine kinase levels and myopathic changes on electromyography should alert the clinician to this complication. The presence of anti‐PM‐Scl autoantibodies in association with overlap syndromes may have a more favourable prognostic significance.

Bronchiolitis Obliterans with Organizing Pneumonia (BOOP) Heralding Anti-Jo-1-Positive Polymyositis

We report a 51-year-old man who presented with 3 weeks of polyarthritis with fever, nonproductive cough, bibasilar crackles, tachypnea, and hypoxia. Initial laboratory data showed an increased erythrocyte sedimentation rate, rheumatoid factor, and anti-Jo-1 antibody. Imaging studies showed bilateral lower lobe infiltrates of the lung. A transbronchial biopsy specimen revealed characteristic findings for bronchiolitis obliterans organizing pneumonia (BOOP). About 6 months later, he developed profound proximal muscle weakness with a dramatic increase in creatine phosphokinase and aldolase and a further elevation of anti-Jo-1. Muscle biopsy specimen findings were consistent with polymyositis.This represents an unusual case in which BOOP occurred at the onset of an illness initially suggestive of rheumatoid arthritis (RA). The anti-Jo-1-positivity led to close follow up and later discovery of evolution into polymyositis. BOOP can be an early feature of polymyositis as well as RA.

Thyrotoxicosis Resembles Lyme Disease

Letters15 May 1991Thyrotoxicosis Resembles Lyme DiseaseCarolyn B. Becker, MD, David H. Trock, MDCarolyn B. Becker, MDSearch for more papers by this author, David H. Trock, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-114-10-914_2 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptTo the Editors: The diagnosis of Lyme disease rests on both clinical (1) and serologic (2) findings. Patients living in endemic areas, however, may be treated for Lyme disease despite negative serologic findings. We have recently seen three such patients who actually suffered from undiagnosed thyrotoxicosis.Patient 1. A healthy 41-year-old man had a 2-month history of excessive fatigue, malaise, profound proximal muscle weakness, and bilateral burning hip and thigh pains, preceded by a flu-like illness with fever and sore throat. He lived in a wooded, deer-infested area of Connecticut. A 2-week course of antibiotics for presumed Lyme disease did...

Diagnosis of Neuropathic vs Myopathic Disease-Reply

In Reply.— Professor Rogoff correctly points out the value of electrodiagnostic testing in the diagnosis of strictly neuropathic vs myopathic disease states. While electrodiagnostic tests may differentiate pathogenesis in some patients with muscle weakness, these tests may not clearly separate those patients with diabetic amyotrophy from those with the multiplicity of neurologic, muscular, and end-plate abnormalities seen in patients with neoplasms. Therefore, use of the provisional term myopathy was justified by the clinical picture of profound proximal muscle weakness in an elderly man with a pancreatic mass. Subsequent events of the hospital course, as described, did not allow for performance of elective muscle biopsy or electromyography. Nevertheless, concern over the presence of an underlying malignant neoplasm would have made tumor search the primary goal, regardless of interpretation of electromyographic pattern.