Tasleem Azka, Cavaghan Melissa, Czosnowski Quinn A, Saeed Zeb
Internal Medicine, Indiana University Health Ball Memorial Hospital, Muncie, USA.
Endocrinology and Diabetes, Indiana University Health, Indianapolis, USA.
Cureus. 2021 Dec 6;13(12):e20214. doi: 10.7759/cureus.20214. eCollection 2021 Dec.
Cushing's syndrome (CS) is an immunocompromised state characterized by impaired cellular and adaptive immunity due to hypercortisolism. This imbalance in the immune system leads to a high risk of opportunistic infections which can potentially prove fatal. In such patients, mortality can be reduced with early diagnosis and effective management of the underlying hypercortisolism. In this case report, we describe how prompt reduction of cortisol levels using a low dose continuous etomidate infusion was pivotal in effective treatment of an opportunistic infection, disseminated nocardiosis, in a 29-year-old female with Cushing's syndrome. We also discuss how treatment with antibiotics including empiric therapy with Imipenem and sulfamethoxazole/trimethoprim (SMX/TMP) and definite therapy as per susceptibility testing, with amikacin, SMX/TMP, and doxycycline helped to prevent adverse outcomes. Through this case, we aim to emphasize that infiltrates or cavitary lesions on the computed tomography (CT) scan of the chest in a patient with Cushing's syndrome should raise concern for nocardiosis, and prompt management with antibiotics should be initiated. Similarly, disseminated nocardiosis should always raise concern for possible immune deficiency states like Cushing's syndrome. Our case is unique in detailing the significance of using etomidate to acutely lower cortisol levels in a patient with endogenous CS and widespread invasive opportunistic infection. The pharmacology aspects of the Etomidate, in this case, have been published in the Journal of Pharmacy Practice and cited appropriately in this article.
库欣综合征（CS）是一种免疫功能低下状态，其特征为因皮质醇增多症导致细胞免疫和适应性免疫受损。免疫系统的这种失衡会导致机会性感染的高风险，而这些感染可能会致命。对于此类患者，通过早期诊断和有效控制潜在的皮质醇增多症可降低死亡率。在本病例报告中，我们描述了如何通过低剂量持续输注依托咪酯迅速降低皮质醇水平，这对一名患有库欣综合征的29岁女性有效治疗机会性感染——播散性诺卡菌病起到了关键作用。我们还讨论了使用抗生素治疗，包括用亚胺培南和磺胺甲恶唑/甲氧苄啶（SMX/TMP）进行经验性治疗，以及根据药敏试验用阿米卡星、SMX/TMP和强力霉素进行确定性治疗，如何有助于预防不良后果。通过这个病例，我们旨在强调，库欣综合征患者胸部计算机断层扫描（CT）上的浸润或空洞性病变应引起对诺卡菌病的关注，并应立即开始用抗生素进行治疗。同样，播散性诺卡菌病应始终引起对可能的免疫缺陷状态如库欣综合征的关注。我们的病例独特之处在于详细阐述了在患有内源性库欣综合征和广泛侵袭性机会性感染的患者中使用依托咪酯急性降低皮质醇水平的重要性。在本病例中，依托咪酯的药理学方面已发表在《药学实践杂志》上，并在本文中适当引用。
