ArticleAACE endocrinology and diabetes
Persistent Adrenocortical Insufficiency After Long-Term Metyrapone Treatment for Cushing's Disease.
Article in AACE endocrinology and diabetes. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Introduction: Cushing's disease is caused by pituitary tumors that secrete excess adrenocorticotropic hormone (ACTH). Metyrapone is widely used for medical management as a bridge to transsphenoidal pituitary surgery. Case Report: An 80-year-old man presented with severe hypercortisolemia (101 μg/dL [reference range, 5-23 μg/dL]) and elevated plasma ACTH, 228 pg/mL [reference range, 7.2-63.3 pg/mL]). Initial high-dose dexamethasone suppression and corticotropin-releasing hormone (CRH) tests suggested ectopic ACTH syndrome; however, extensive imaging failed to identify a source. Metyrapone was initiated and escalated to 3000 mg/d, followed by block-and-replacement with hydrocortisone (20 mg/d). After 4 years, repeat CRH testing and dexamethasone suppression supported Cushing's disease. Combined cavernous and inferior petrosal sinus sampling localized ACTH hypersecretion to the right pituitary. Transsphenoidal surgery confirmed a corticotroph pituitary neuroendocrine tumor. Despite tumor resection and metyrapone discontinuation, cortisol levels remained undetectable for more than 1 year. Discussion: Liquid chromatography-tandem mass spectrometry demonstrated markedly reduced mineralocorticoids, glucocorticoids, and adrenal androgens, indicating global adrenocortical dysfunction. Adrenal androgens are typically increased during metyrapone therapy, suggesting broader effects of long-term metyrapone on adrenal steroidogenesis beyond selective 11β-hydroxylase inhibition. Although postoperative glucocorticoid supplementation may have contributed to adrenal suppression, preserved ACTH responsiveness to CRH supports intact hypothalamic-pituitary signaling with impaired adrenal recovery. Conclusion: This case suggests that prolonged global adrenocortical dysfunction persisting over 1 year after metyrapone discontinuation. Clinicians should be aware of this potential complication and ensure appropriate glucocorticoid replacement and careful long-term monitoring.
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