SAT-015 - Severe Psychosis Unmasking Cushing'S Disease with Complete Endocrine Recovery

Introduction:
Hypercortisolism frequently induces neuropsychiatric disturbances; however,
acute psychosis as the initial clinical presentation of Cushing’s disease (CD) is exceptionally rare
and often leads to diagnostic delays. This case highlights the rapid resolution of severe
psychiatric symptoms following surgical intervention, despite significant perioperative
complications including cerebrospinal fluid (CSF) leak and meningitis.

Case Description:
A 29-year-old female with no prior psychiatric history presented with acute
psychosis, including hallucinations and delusions lasting 15 days. Physical examination revealed
classic Cushingoid features, including violaceous striae and facial swelling. Laboratory
evaluation confirmed severe hypokalemia (2.2 mmol/L) and hypertension. A 1 mg
dexamethasone suppression test showed failed suppression (cortisol >20 µg/dL) with an
elevated ACTH of 191 pg/mL. Pituitary MRI identified a 1.0 cm hemorrhagic macroadenoma.
Due to the severity of the psychosis, she was initiated on mifepristone 200 mg daily as a bridge
to surgery.
The patient underwent transsphenoidal pituitary tumor resection, which served as the clinical
anchor for her recovery. On postoperative day (POD) 2, AM cortisol levels dropped to 1.2 µg/dL,
confirming biochemical remission. However, her recovery was complicated by a CSF leak and
pneumococcal meningitis. She required a 14-day course of IV antibiotics and underwent
endoscopic CSF leak repair on POD 18.
Following discharge, the patient remained on a tapering hydrocortisone regimen. By
postoperative month 4, her AM cortisol improved to 5.1 µg/dL, allowing for the complete
discontinuation of glucocorticoid replacement. At 9 months post-surgery, laboratory results
demonstrated sustained stability with a normal ACTH (13.1 pg/mL), stable free T4 (1.0 ng/dL),
and suppressed late-night salivary cortisol ( < 50 ng/dL). Clinically, her psychiatric symptoms and
physical striae resolved entirely. A follow-up MRI at 6 months post-resection showed expected
postsurgical changes with no evidence of tumor recurrence.

Conclusion:
This case illustrates that acute psychosis can be the sentinel sign of an ACTH-
secreting adenoma. It demonstrates that even when complicated by serious perioperative
events like meningitis, achieving rapid biochemical remission is key to reversing severe
psychiatric manifestations. Long-term multidisciplinary follow-up is essential to confirm the
sustained recovery of the HPA axis and to monitor for potential recurrence.

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