PMC4712425_01
(A) Round and plethoric face of the patient. (B) Abdomen computed tomography of the patient showing normal adrenal glands. (C, D) Sellar magnetic resonance imaging of the patient showing a 1.5-cm, markedly heterogeneous pituitary macroadenoma with left-sided stalk deviation.
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She was obese, and her face was round (Fig. 1A), but she did not show other cushingoid features such as a buffalo hump or abdominal striae. Flat abdomen film and abdomen computed tomography (Fig. 1B) showed marked hepatosplenomegaly and diffuse gallbladder wall edema with normal adrenal glands. Sellar magnetic resonance imaging showed a 1.5-cm heterogeneous pituitary macroadenoma, indicating recent hemorrhage (Fig. 1C and 1D).
Sequential morning urine free cortisol to creatinine ratio (UFCCR) in the patient for 7 days in March and 30 days from April to May 2010.
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We randomly performed serial early morning UFCCR for 7 days under the suspicion of cyclic Cushing syndrome and detected a 7-fold increase in UFCCR from her usual UFCCR (Fig. 2). One month later, a 30-day sequential early morning UFCCR was performed, and the results showed that the cortisol peak between days 22 and 26 was 200-fold higher than that of the other days (Fig. 2).
Tissue pathology of the pituitary tumor. The tumor cells were arranged in a trabecular and diffuse pattern (A: H&E, x40). They were with granular eosinophilic cytoplasm, occasionally forming focal pseudovascular rosettes (B: H&E, x200). On immunohistochemistry, the tumor was positive for adrenocorticotropic hormone (C: ACTH, x100), but growth hormone (D: GH, x100), prolactin, thyroid stimulating hormone, follicle stimulating hormone, and luteinizing hormone were all negative (data not shown). These pictures were provided by courtesy of Dr. Se Hoon Kim in Yonsei University.
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Hospital. Histopathology revealed that the tumor cells were arranged in a trabecular and diffuse pattern (Fig. 3A), with granular eosinophilic cytoplasm and occasionally forming focal pseudovascular rosettes (Fig. 3B). Immunohistochemistry for pituitary hormones was positive only for ACTH (Fig. 3C and 3D).