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Refractory hypokalaemia and hypertension with metabolic alkalosis: an acute presentation of Cushing’s disease secondary to a pituitary macroadenoma
  1. Najeeb Zaheer Shah1,2,
  2. Shah Malik1,
  3. Thozhukat Sathyapalan1,2 and
  4. Kamrudeen Mohammed1
  1. 1Diabetes and Endocrinology, Hull University Teaching Hospitals NHS Trust, Hull, UK
  2. 2Department of Academic Diabetes, Endocrinology and Metabolism, University of Hull, Hull, UK
  1. Correspondence to Dr Najeeb Zaheer Shah; nzshah17{at}


A 68-year-old woman presented with right arm cellulitis, not responsive to oral antibiotics. Intravenous antibiotics were commenced, and an ultrasound scan confirmed a collection that was surgically drained. She developed refractory hypokalaemia with normal magnesium, no gastrointestinal losses and no iatrogenic cause. She was hypertensive, hyperglycaemic, alkalotic, clinically obese with proximal myopathy and skin bruising. These clinical findings and refractory hypokalaemic hypertension with metabolic alkalosis raised a suspicion of Cushing’s syndrome (CS). 24-hour urinary free cortisol (24 hours) was grossly raised on two occasions. The adrenocorticotropic hormone (ACTH) was significantly raised at 154 ng/L, confirming ACTH-dependant CS. A CT scan of the thorax, abdomen and pelvis excluded an ectopic source of hypercortisolaemia. MRI pituitary revealed an invasive macroadenoma. Treatment with endoscopic debulking resulted in the resolution of hypokalaemia and metabolic alkalosis with significant improvement in hyperglycaemia and hypertension.

  • metabolic disorders
  • pituitary disorders
  • fluid electrolyte and acid-base disturbances

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  • Contributors NZS and KM conceived the presented work. NZS wrote the first draft of the manuscript and all subsequent revisions. SM obtained the relevant images for the manuscript. SM, TS and KM made multiple comments and critiques of the manuscript. TS and KM provided overall supervision of the project.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.