Management of Known Cushing's Disease in a Nonsurgical Candidate Secondary to a History of Hemorrhagic Stroke Case Report.

Background: Cushing's disease can present with hyperglycemia, hypertension, electrolyte abnormalities, headaches, confusion, gastrointestinal (GI) bleeds, and more. Macroadenomas of the pituitary causing cortisol excess can complicate these cases of patients with a recent hemorrhagic stroke with the medical complexities found within both disease processes of hemorrhagic stroke and Cushing's disease. Case: This is a 61-year-old female patient who returned from a rehabilitation facility after confusion, abdominal pain, vaginal bleeding, and weakness. History included hypertension, hypothyroidism, type 2 diabetes mellitus, suspected Cushing's disease, hemorrhagic stroke, and a lumbar compression fracture. Blood pressure was 195/87 with a potassium of 2.0. X-ray showed a nonobstructive bowel gas pattern, and computed tomography (CT) of the abdomen and pelvis was concerning for stercolitis, multiple pancreatic cysts, and atelectasis. Insulin, intravenous (IV) fluids, and electrolyte replacement were initiated. She developed a deep venous thrombosis (DVT) in the right lower extremity and was placed on enoxaparin. Worsening of GI bleeding occurred, and an inferior vena cava filter was placed. Osilodrostat was started. Colonoscopy showed ulcerations in the sigmoid colon. Pathology showed no findings concerning dysplasia or malignancy. Osilodrostat was increased to 2 mg twice a day. She was discharged home, with follow-ups for resection of her macroadenoma, biopsy of uterine endometrium, and genetic testing. Discussion/Conclusions: The clinical manifestations found in this case are largely due to hypercortisolism, and while she is going to still have additional testing including biopsy of the fibroid, colorectal surgical evaluation for hemorrhoids, and genetic testing with confirmatory lab work per endocrinology outpatient, her illness was medically uncontrolled. As osilodrostat takes a couple weeks to a couple months for full control with frequent cortisol checks, adjustments including insulin, blood pressure control, electrolyte corrections, and more should be considered.