• thymic carcinoid
• Cushing’s syndrome

A 34 year old man presented with a three week history of depression and lack of communication. He was found to be hypertensive a year previously and was taking enalapril. Six months earlier he had diabetes mellitus diagnosed when he developed osmotic symptoms with significant weight loss (6 kg). He was on glibenclamide and metformin with uncontrolled blood glucose for which insulin was started three weeks before presentation. He complained of difficulty in climbing stairs and getting up from a sitting position. On examination he was depressed, withdrawn, and non-communicative. His body mass index was 17.62 kg/m² and blood pressure 160/100 mm Hg. He had thin atrophic skin, facial plethora, and pigmentation over his knuckles. Systemic examination was essentially normal except for proximal muscle weakness. Laboratory investigations were: haemoglobin concentration 132 g/l, sodium 132 mmol/l (normal range 135–145 mmol/l), potassium 3.0 mmol/l (3.3–4.9 mmol/l), fasting plasma glucose 4.5 mmol/l (3.5–6.0 mmol/l), urea 6.64 mmol/l (2.9–8.9 mmol/l), creatinine 61.8 μmol/l (44–150 µmol/l), albumin 38 g/l (36–50 g/l), calcium (corrected for albumin) 2.1 mmol/l (2.15–2.58 mmol/l), and inorganic phosphate 0.9 mmol/l (0.81–1.45 mmol/l). Plasma cortisol at 8.00 pm was 1200 nmol/l (200–400 nmol/l). Arterial blood gas analysis showed metabolic alkalosis. Chest radiography was unremarkable. Electrocardiography showed left ventricular hypertrophy.