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A tale of three tumours
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The diagnosis of Cushing’s syndrome is confirmed by the low dose dexamethasone test and the considerably increased 24 hour urinary free cortisol concentrations. The imaging studies show tumours in the pituitary and the adrenal, while a large anterior mediastinal mass is seen on the thoracic image. The presence of hyperpigmentation, further supported by a raised ACTH level makes ACTH dependent Cushing’s syndrome probable. In this case, the non-suppressibility of cortisol to a high dose of dexamethasone and the short duration of symptoms point to ectopic Cushing’s syndrome. The common causes for ectopic Cushing’s syndrome are small cell carcinoma of the lung, bronchial carcinoid, islet cell tumours of the pancreas, and thymic carcinoids. Therefore the probable cause of ectopic Cushing’s syndrome in this case is the mediastinal mass, the first possibility being a carcinoid tumour arising from the thymus and a malignant thymoma being a rarer possibility.
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