Successful Use of Continuous Etomidate Intravenous Infusion for Treatment of Ectopic Cushing Syndrome due to Small Cell Lung Carcinoma With Perforated Sigmoid Diverticulitis.

Background/Objective: We present a case of ectopic Cushing syndrome (CS) due to small cell lung cancer with a rare complication of perforated sigmoid colon diverticulitis managed by continuous etomidate intravenous infusion (CEII) with adequate control of hypercortisolism in the perioperative period during nothing by mouth state. Case Report: A 73-year-old woman who was diagnosed with small cell lung cancer 9 weeks ago and severe CS 3 weeks ago presented with lower abdominal pain and constipation. She was afebrile with hyperpigmentation of skin and left lower quadrant tenderness. Moon facies, buffalo hump, or abdominal striae were absent. Laboratory data revealed hypokalemia, hyperglycemia, 24-hour urine free cortisol 3963.5 μg/24 h (reference range 4-50), serum cortisol >60 μg/dL (reference range 5-25), and adrenocorticotropic hormone 90 pg/mL (reference range 6-50). Computed tomography scan suggested perforated sigmoid colon diverticulitis. She developed bacteremia and underwent Hartmann's procedure. CEII started at a rate of 0.02 mg/kg/h and adjusted every 6 hours based on serum cortisol levels. CEII achieved the desired cortisol level of 20 to 30 μg/dL within 48 hours and maintained it afterwards. The patient was successfully transitioned to oral therapy and discharged after 10 days. Discussion: Perioperative management of severe hypercortisolemia in CS is limited by unavailability of oral route and time-dependent drug titration. Etomidate, known as anesthetic agent, has adrenocortical inhibitory effects and can be administered intravenously; however, safety needs to be assured with standardized protocol along with mental status, electrolyte, and acid-base monitoring. Conclusion: CEII protocol can be safely and effectively implemented to manage severe CS in a community hospital.