J Korean Endocr Soc.  2008 Feb;23(1):44-50. 10.3803/jkes.2008.23.1.44.

A Case of Pneumocystis Carinii Pneumonia and Cutaneous Nocardiosis Associated with Ectopic ACTH Syndrome

• Jung HS
• Lee SH
• Kim HY
• Chu EH
• Lee KW
• Kang MJ
• Kim JH
• Kwon HS
• Yoon KH
• Cha BY
• Son HY

• KMID: 2063549
• DOI: http://doi.org/10.3803/jkes.2008.23.1.44

Abstract

Cushing's syndrome is characterized by hypercortisolism and impairment of cell-mediated immune function, increasing the risk of opportunistic infection, as occurs in other immunocompromised groups such as organ transplant recipients, patients with lymphoreticular malignancy, or acquired immunodeficiency syndrome. We report a case of a 68-year-old woman who was affected with pneumocystis carinii pneumonia (PCP) 8 years ago and cutaneous nocardiosis this year. The patient was diagnosed with ectopic ACTH syndrome 8 years ago, but no ectopic ACTH secreting focus was found in radiologic imaging studies. She recovered from PCP and cutaneous nocardiosis after antibiotic (trimethoprim-sulfamethoxazole) administration. After the infection resolved, she underwent laparoscopic bilateral adrenalectomy and was not longer hypercortisolemic.

Keyword

ectopic ACTH syndrome; pneumocystis carinii pneumonia; nocardiosis

MeSH Terms

Acquired Immunodeficiency Syndrome
ACTH Syndrome, Ectopic
Adrenalectomy
Adrenocorticotropic Hormone
Aged
Cushing Syndrome
Female
Humans
Nocardia Infections
Opportunistic Infections
Pneumocystis
Pneumocystis carinii
Pneumonia, Pneumocystis
Transplants
Adrenocorticotropic Hormone
Nocardia Infections

Figure

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  Fig. 1 Chest CT shows focal peripheral consolidation in posterior subpleura of right upper lobe (arrow).

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  Fig. 2 Abdominal CT shows bilateral adrenal hyperplasia.

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  Fig. 3 Sella MRI shows a 5.6 mm sized lesion in left anteroinferior aspect of the sella suggesting microadenoma (B, arrow). Compared to the size measured 4 years ago (A, arrow), there has been no significant interval change.

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  Fig. 4 Ultrasonography (A) and MRI (B, C) show an irregular shaped heterogenous lesion in the epichondylar region of right elbow, suggesting infectious lymphadenitis with necrotic change and surrounding cellulitis (arrow).

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  Fig. 5 The changes of serum cortisol (µg/dL), 24hr urine free cortisol (µg/day) and the dosage of ketoconazole.

Reference

1. Sarlis NJ, Chanock SJ, Nieman LK. Cortisolemic indices predict severe infections in Cushing syndrome due to ectopic production of adrenocorticotropin. J Clin Endocrinol Metab. 2000. 85:42–47.

2. Graham BS, Tucker WS Jr. Opportunistic infections in endogenous Cushing's syndrome. Ann Intern Med. 1984. 101:334–338.

3. Lionakis MS, Kontoyiannis DP. Glucocorticoids and invasive fungal infections. Lancet. 2003. 362:1828–1838.

4. Inamadar AC, Palit A. Primary cutaneous nocardiosis: a case study and review. Indian J Dermatol Venereol Leprol. 2003. 69:386–391.

5. Lee SH, Suh CW, Choi JH, Sung KJ, Moon KC, Koh JK. A case of primary cutaneous sporotrichoid nocardiosis caused by Nocardia asteroides. Ann Dermatol. 1999. 11:90–93.

6. Shimizu A, Ishikawa O, Nagai Y, Mikami Y, Nishimura K. Primary cutaneous nocardiosis due to Nocardia nova in a healthy woman. Br J Dermatol. 2001. 145:154–156.

7. Smego RA Jr, Moeller MB, Gallis HA. Trimethoprim-sulfamethoxazole therapy for Nocardia infections. Arch Intern Med. 1983. 143:711–718.

8. Lee HJ, Kim HS, Suh HS, Sung KJ, Koh JK. A case of primary cutaneous alternariosis with iatrogenic Cushing syndrome. Korean J Dermatol. 1996. 34:495–499.

9. Choi HU, Sung KH, Lee WW, Bae JH, Lee SK. A case of blastomycosis-like pyoderma. Korean J Dermatol. 2003. 41:936–939.

10. Han SY, Kim CH, Son KP, Kim JK, Byun HW, Kim YS, Jeong IK, Woo HJ, Hyun IG, Jung KS, Lee ES. A case of disseminated coccidioidomycosis involving lung and skin in patient with diabetes mellitus and iatrogenic Cushing's syndrome. Tuberc Respir Dis. 2005. 58:399–403.

11. Lee SY, Oh YM, Lim CM, Lee SD, Koh YS, Kim WS, Kim DS, Kim WD, Shim TS. A case of pulmonary nocardiosis in the patient with Cushing's disease. Tuberc Respir Dis. 2004. 57:61–65.

12. Lee JK, Chun HK, Hahn JH, Son HS, Yoon KH, Kang MI, Cha BY, Lee KW, Son HY, Kang SG. Two cases of cryptococcosis in patients with Cushing's syndrome and diabetes mellitus. J Kor Soc Endocrinol. 1995. 10:58–64.

13. Kang CI, Kim SH, Kim HB, Oh MD, Kim SY, Choe KW. Disseminated cryptococcosis in a patient with pituitary Cushing's disease. Korean J Intern Med. 2003. 18:199–201.

14. Kim DS, Park SK, Choi WH, Kim TW, Choi YY, Jeon SC, Ryu JS. Pneumocystis carinii pneumonia associated with a rapid reduction of cortisol level in a patient with ectopic ACTH syndrome treated by octreotide and ketoconazole. Exp Clin Endocrinol Diabetes. 2000. 108:146–150.

15. Kim SM, Kim JH, Park MJ, Park CS, Jun JM, Oh HJ, Park YK, Sin YH, Kim JK, Park JI. A case of nocardiosis with CMV (cytomegalovirus) infection after third renal transplantation in China. J Korean Soc Transplant. 2005. 19:63–68.

16. Huh D, Lee JM, Jung YS, Jang ID, Kam BK, Kim MS, Kim JK, Lee SR, Lee JS. Two cases of nocardial infection in the renal transplant recipient. J Korean Soc Transplant. 1997. 11:131–136.

17. Jung HJ, Kim BD, Lee EY, Cho KH, Bae SW, Park JB, Kim YG, Do JY, Yoon KW. A case of disseminated nocardiosis in kidney transplant recipient. Korean J Nephrol. 1999. 18:634–638.

18. Yang CW, Kim YS, Bang BK, Park JH, Chae EY, Kim YK, Park EJ. A case of empyema thorax and intraabdominal abscess caused by nocardiac species. Korean J Nephrol. 1999. 18:825–829.

19. Bakker RC, Gallas PR, Romijn JA, Wiersinga WM. Cushing's syndrome complicated by multiple opportunistic infections. J Endocrinol Invest. 1998. 21:329–333.