Continuous Etomidate for the Management of Cushing's Syndrome Complicated by Pulmonary Nocardiosis

Severe Cushing's syndrome is associated with significant complications including opportunistic infections. In the setting of infection, urgent reduction of circulating cortisol is warranted and commonly used oral medications have a slow onset of effect. Here we describe a 29-years old female who presented to an outside hospital with symptoms of untreated Cushing's syndrome on ketoconazole. Following identification of a pulmonary Nocardia spp infection, she was transferred for a higher level of care. Her initial serum ACTH and cortisol levels after transfer were 106pg/mL and 53.7mCg/dL respectively. Given the severity of her nocardiosis and lack of response to ketoconazole, the patient was placed in the ICU and started on a continuous etomidate infusion. Her serum cortisol rapidly decreased to 5.7mCg/dL. She was transitioned to metyarapone and the etomidate infusion was weaned to off. The etomidate infusion was well tolerated without adverse effects or need for an advanced airway. Following discontinuation of etomidate, she was found to have a pituitary microadenoma that was resected. The patient was discharged from the hospital on antibiotics for the management of her Nocardia spp infection. In patients with severe Cushing's syndrome, continuous etomidate may be safe and effective for patients who are unresponsive to other therapies.