Pulmonary embolism as the first manifestation of Cushing syndrome in a young woman

Abstract

Cushing syndrome (CS) is associated with an 18-fold higher risk of venous thromboembolism (VTE), mostly during the active phase of the disease, in the postoperative period after transsphenoidal surgery and adrenalectomy, but also after biochemical remission [1]. Although hypercoagulability in CS is attracting more and more attention, there are still no guidelines regarding a standardized anticoagulation regimen in patients with CS [2].We present a case of a young woman diagnosed with CS in the course of pulmonary embolism (PE) event management. To the best of our knowledge, in the literature there are 5 cases of patients with CS whose first presentation was VTE [3][4][5][6].A 35-year-old woman with no significant past medical history, on combined oral contraceptive (COC), presented to the emergency department with acute dyspnoea. Laboratory tests showed an elevated D-dimer concentration (1.62 ug/mL, upper reference limit: 0.5 ug/mL). Computed tomography pulmonary angiography revealed peripheral PE (Fig. 1) and incidental left adrenal gland tumour [20 × 27 mm, precontrast 30 Hounsfield units (HU)] (Fig. 2). Clinically, she presented mild arterial hypertension and hypokalaemia. The COC was discontinued, while anticoagulation therapy (rivaroxaban in a dose of 15 mg twice daily for 3 weeks followed by 20 mg once daily) was initiated, along with antihypertensive treatment and potassium supplementation. The patient was referred to an endocrinologist. In the course of further investigation inherited and acquired thrombophilia were excluded.