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Graves Disease Exacerbation After Pituitary Adenomectomy for Cushing Disease Resulting in an Adrenal Crisis

Aktas, Mehmet K. MD*; Fleseriu, Maria MD*; Weil, Robert J. MD†; Faiman, Charles MD*; Sergev, Orlin T. MD, PhD‡; Reddy, Sethu MD*; Hamrahian, Amir H. MD*

doi: 10.1097/TEN.0b013e3181343553
Case Report

Objective: To describe a patient with Cushing disease who had an exacerbation of Graves disease following surgical resection of a corticotroph pituitary adenoma.

Methods: We present the clinical and biochemical findings of this case, with review of the pertinent literature.

Results: A 39-year-old woman with a history of Graves disease on methimazole presented with a 100-pound weight gain over 12 months. Biochemical evaluation revealed Cushing disease, and she underwent an uncomplicated trans-sphenoidal pituitary adenomectomy surgery. Seven weeks after operation, she presented with an adrenal crisis, despite taking 30 mg of hydrocortisone daily, as a likely consequence of worsening hyperthyroidism despite continued methimazole treatment.

Conclusion: A combination of Graves disease and Cushing syndrome can be a challenging scenario. Successful treatment of hypercortisolism can lead to an exacerbation of hyperthyroidism, with a resultant increase in cortisol clearance, which, in this circumstance, may precipitate an adrenal crisis. Clinicians should be aware of these interactions and monitor such patients closely.

From the *Department of Endocrinology, Diabetes and Metabolism and the †Brain Tumor Institute, Cleveland Clinic Foundation, Cleveland, Ohio; and the ‡Carolina Endocrine Associates, Charleston, South Carolina.

Reprints: Amir H. Hamrahian, MD, Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Desk A53, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.