MON-027 - Cushing'S Disease Presenting with Disseminated Nocardiosis

77 year old man was evaluated in clinic for progressive weight gain, proximal muscle weakness, memory decline, and atraumatic vertebral compression fractures. Laboratory testing revealed abnormal cortisol with ACTH 150. One mg overnight dexamethasone suppression test failed to suppress cortisol (8 a.m. cortisol 30.36 µg/dL; dexamethasone level 508 ng/dL), with elevated late-night salivary cortisol (1.66 µg/dL at 23:30). CT imaging demonstrated a 1.6 × 1.4 × 1.0 cm left-sided pituitary lesion without optic chiasm compression; MRI was contraindicated due to a pacemaker. No adrenal lesions were identified. CT lumbar and thoracic spine revealed acute burst fracture in T6 vertebral body, age-indeterminate burst fracture at L2. He was admitted for severe back pain and underwent kyphoplasty for T6 and L2 burst fractures.
Two months later, patient presented with new L4 and sacral fractures. He was noted to have an abdominal mass on examination, and biopsy of the abdominal wall lesion demonstrated filamentous branching organisms consistent with Nocardia, and antifungal therapy was initiated. CT imaging also revealed a right lower lobe lung mass with cavitation, multifocal subcutaneous, muscular, retroperitoneal nodules, and concern for widespread metastatic disease.
He subsequently underwent endoscopic endonasal resection of the pituitary mass. Pathology confirmed a sparsely granulated corticotroph adenoma. Postoperatively, cortisol levels declined appropriately. His course was complicated by seizure; brain CT revealed multiple ring-enhancing lesions consistent with CNS nocardiosis. Despite antimicrobial therapy and drainage of multiple soft tissue abscesses, serial imaging showed progression of intracranial abscesses and new pulmonary cavitary disease requiring biopsy. Given clinical deterioration, the patient elected for hospice care.

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