Clinical Dilemma of Rheumatiod Artritis Onset in a Patient with Severe and Active Cushing Disease

Presentation Number: SAT-379
Date of Presentation: March 7th, 2015

Maria Antonenko1, Natalya Volkova*2, Irina Dzherieva3, Ilia Davidenko4, Igor Reshetnikov5, Aida Gulmagomedova3 and Lilia Ganenko3
1Rostov State Med Univ, Rostov-on-don, Russia, 2The Rostov State Medical University, Rostov-on-Don, Russia, 3Rostov State Medical University, Rostov on Don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, Rostov-on-Don, Russia


Endogenous Cushing syndrome is an immunosuppressive condition. It is well-known that after resolution of hypercortisolism patients have increased incidence of autoimmune diseases. Here we opposite present a clinical case of onset of rheumatoid arthritis (RA) in a patient with active Cushing Disease (CD). The patient female 46 y.o. was suspected to have Cushing syndrome in 2011 when dysplastic obesity, face plethora, decompensation of diabetes mellitus appeared. CD was established on 1-mg DST (plasma cortisol after test 458,9 nmol/l), UFC 843,3 mcg/day, midnight plasma cortisol (MPC) 386,4 nmol/l, basal ACTH 79 pg/ml and 129 pg/ml, and pituitary microadenoma 6mm. The diagnosis of CD was confirmed in tertiary endocrinology centre by usage of petrosal venous sinus catheterization. In 2012 there was performed transsphenoidal surgery by experienced neurosurgeon. However, postoperative adrenal failure didn’t develop. Six months after operation there was performed laboratory screening for CS: plasma cortisol after DST 1 mg 250 nmol/l, UFC 402 mcg/day, MPC 280 nmol/l, basal ACTH 65 pg/ml were consistent with persistent CD. Patient refused a second operation and escaped from medical control. After 6 months, she appeared with clear evident clinical features of hypercortisolism. She also complained of inability to raise hands due to severe pain. The diagnosis of persistent CD was again confirmed: plasma cortisol after DST 1 mg 450 nmol/l, UFC 832 mcg/day, MPC 423 nmol/l, basal ACTH 86 pg/ml. Patient chose medical treatment with steroidogenesis blockers (ketoconazole). In order to establish the cause of inability to raise hands there were performed neck CT and shoulder joints radiography. The specific signs of RA were detected. The diagnosis of RA was confirmed based on inflammatory arthritis involving more three joints and positive rheumatoid factor. When the diagnosis was established, and methotrexate was prescribed by rheumatologist, there appeared a serious clinical dilemma because of combined treatment with ketoconazole and methotrexate and, as a result, their potential hepatotoxicity. Because of patient refusal of pituitary and adrenal surgery, limited pasireotide availability and other medical treatment in Russia, the only way of treatment was to receive steroidogenesis blocker and symptomatic treatment for RA. Patient has already been on this therapy for one year and feels tolerable. Firstly, to best of our knowledge, there is a very limited data about onset of autoimmune diseases in severe and active hypercortisolism. Secondly, this case illustrates a serious clinical dilemma concerning treatment of hypercortisolism and concommitant autoimmune diseases because of high hepatotoxicity of commonly used treatment for both conditions. Best option in this case would have been the prescription of somatostatin analogues equal for as hypercortisolism as arthritis.


Nothing to Disclose: MA, NV, ID, ID, IR, AG, LG