bronchial carcinoids represent a small portion of all pulmonary tumors and about 15% of them are associated with ectopic acth secretion , which represents 110% of cushing s syndrome cases , , . cushing s syndrome ( cs ) is the result of chronic exposure to increased concentration of cortisol hormone exogenous or endogenus , and it is generally associated with central obesity , metabolic syndrome , hypertension . neuropsycological disturbances are also frequently observed , including depression , emotional irritability , sleep disturbance and cognitive deficits that can be the first manifestation perceived by family members of patients affected by cs . treatment is based on decreasing of cortisol levels in blood , through medical or surgical approaches . we describe a case of typical bronchial carcinoid associated with a cushing s like syndrome . a 26 year - old severe obese male with an history of anxiety over the last 5 years was admitted to our department of respiratory medicine referring poorly cough , fever ( 39  c ) , sputum and shortness of breath . he was a nonsmoker and his weight , height and body mass index were 163  kg , 1.90  m and 45.15  kg    m , respectively . a physical exam revealed round facies , extensive purple striae on his abdomen and marked central obesity , mimicking cushingoid features . auscultation of the chest revealed hypophonesis and reduction of breath sound of the basal right hemithorax . pulse was regular and blood pressure normal ; the haemoglobin oxygen saturation was 91% in room air . a chest radiograph showed a lift of right hemidiaphragm with ipsilateral scanty pleural effusion ( fig . 1 ) . the clinical and radiological data suggested the diagnosis of pneumonia and the patient was treated with ciprofloxacin 400  mg iv bid and systemic steroids for 10 days . the treatment determined a substantial improvement of clinical condition , but did not modify significantly chest imagines . subsequently the patient performed a computed tomography that revealed the presence of a solid mass in the bronchus intermedius associated with a complete atelectasis of middle and lower right lobe ( fig . fibreoptic bronchoscopy revealed a pale tissue with irregular margins measuring approximately 1  cm in diameter and obliterating completely the bronchus intermedius ( fig . the endobronchial biopsies showed fibrinoid material and microcalcifications in the contest of a nonspecific granulation tissue but were not conclusive for a diagnosis . the patient underwent a rigid bronchoscopy for diagnostic purpose and for partial resection of the intraluminal mass . histophatological examination of endobronchial removed samples showed a typical carcinoid tumor with a trabecular pattern and without areas of necrosis , < 2 mitoses per 2  mm detected by ki67 immunostaining , high cd56 and high chromogranin expression indicating neuroendocrine differentiation . on the basis of diagnosis of neuroendocrine tumor and cushingoids features a blood test was carried out which demonstrated normal levels of acth and cortisol . the determination of a twenty four hour urinary free cortisol resulted normal and a high - dose dexamethasone suppression test ( 2  mg every 6  h for eight doses ) induced a partially suppression of acth secretion . moreover , the patient underwent a brain mri that excluded the presence of a pituitary microadenoma . a flexible bronchoscopy performed two months later showed a complete recanalization of bronchus intermedius , with a partial unblocking of middle and lower bronchi ( fig . surgical resection was considered as therapy of choice , but bilobectomy was not performed because of elevated intraoperative risk associated to the severe obesity and respiratory failure . the patient was adviced a dietary treatment and a conservative initial bronchoscopic treatment for tumor eradication . despite of prescription the patient was not able to lose weight ( just 10  kg in one year ) , he still presents persistent psychiatric disorders and severe obesity . two rigid bronchoscopies were performed during the year to avoid the local growth of the tumor and control the possible differentiation of typical ( tc ) versus atypical ( ac ) histological type of pulmonary carcinoid . carcinoids account for 12% of all pulmonary neoplasms in adults and approximately 2530% of all carcinoid tumors , , , , , , , , , , , , , , , . they are considered to be a low grade malignancy belonging to the spectrum of neuroendocrine tumors . in 2004 , the who devised a new classification for bronchopulmonary carcinoids based upon a spectrum of clinicopathological entities ranging from hyperplastic neuroendocrine cell lesions ( carcinoid tumorlets , diffuse idiopathic pulmonary neuroendocrine cell hyperplasia ) to high grade neuroendocrine tumors ( small cell carcinoma and large cell neuroendocrine carcinoma ) . the initial presentation can be in the parenchyma or mainly in the airways and are described as bronchial carcinoids . approximately 1020% of pulmonary carcinoids are atypical carcinoids ( ac ) , 8090% are typical carcinoids ( tc ) . typical carcinoids are well differentiated , can exhibit distinct recognized histologic pattern ( insular , trabecular , glandular , mixed or undifferentiated ) and rare mitoses . they usually present as perhilar masses and are generally asymptomatic ; however some patients may present recurrent pneumonia , cough , hemoptysis and chest pain . ectopic secretion of biologically active hormones is not uncommon , in particular corticotrophin and growth hormone and it occurs in fewer of 5% of patients with these tumors . conversely , atypical carcinoids represent an intermediate grade neuroendocrine tumors ; they may exhibit increased nuclear atypia , focal necrosis or high mitotic indices and their clinical course is aggressive with an high incidence of mediastinal lymphnode metastases and a 5-year survival rate of 4075% . surgical resection is the preferred treatment of bronchopulmonary carcinoid tumors , anyway the improvement of diagnostic and therapeutic techniques and further understanding of tumor biology are driving new minimally invasive approaches to diagnosis and therapy of these tumors . recent literature reports that the initial bronchoscopic treatment seems to be a justifiable approach for bronchial carcinoids instead of immediate surgical exploration and resection , because of an excellent long term outcome . surgery could be associated to an elevate intraoperative risk , the choice of treating with rigid bronchoscopy can reduce the risk and improve the quality of life of the patient , although it does not produce a radical resolution . cushing s syndrome can be caused by an excess acth production by a pituitary corticotroph adenoma , an extrapituitar tumor ( ectopic acth syndrome ) or , very rarely , by a tumor secreting crh ( ectopic crh syndrome ) . ectopic acth secretion occurs in 1520% of patients with acth dependent cushing s syndrome with the lung being the origin of over 45% of acth - producing tumors ( ectopic ) , followed by thymus ( 11% ) and pancreas ( 8% ) . cushing s syndrome is characterized by presence of central obesity , associated with systemic arterial hypertension , hyperlipidemia , impaired glucose tolerance or diabetes and hypercoagulability . a percentage between 50 and 80% of cushing syndrome patients meet  diagnostic and statistical manual of mental disorders iv criteria of major depression  , while a minority of them have other psychopathological manifestations including mania , anxiety and cognitive disfunction . has been also reported suicidal tendency in patients with cs and the presence of depressive symptoms can be an early manifestation of cs . psychological and psychiatric symptoms improve with the normalization of cortisol levels in blood , obtained with surgical approach , , , , , , . in conclusion the evidence of central obesity , purple striae on the abdomen , prominent eyes , round facies , skin hyperpigmentation and the concomitant and early appearance of psychological disorder , in a patient affected by typical bronchial carcinoid , was strongly suggestive of cushing s syndrome , but the diagnosis was not confirmed by laboratory findings , although it is not possible completely to exclude the periodic secretion of ectopic cortisol acth / crh correlated .
cushing s syndrome occurred in 15% of cases of bronchial carcinoids . in this paper 
 we describe a case of typical bronchial carcinoid in a nonsmoker young male with clinical manifestations mimicking a cushing s syndrome . 
 the patient performed chest radiograph and computed tomography . 
 fiberoptic bronchoscopy revealed the presence of an endobronchial mass occluding the bronchus intermedius . 
 a rigid bronchoscopy was necessary for the conclusive diagnosis and for partial resection of the intraluminal tumor . 
 despite of the presence of cushingoid features , the normal blood levels of acth and cortisol excluded the coexistence of a cushing s syndrome .