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A 44 Age - year Age - old Age man Sex had been diagnosed Clinical_event with LCNEC Disease_disorder of the thymus Biological_structure with bone Biological_structure metastasis Sign_symptom at a different Nonbiological_location hospital Nonbiological_location 3 Date years Date previously Date .
The serum levels of ACTH Diagnostic_procedure and cortisol Diagnostic_procedure were elevated Lab_value , but brain Biological_structure magnetic Diagnostic_procedure resonance Diagnostic_procedure imaging Diagnostic_procedure revealed that his pituitary Detailed_description gland Detailed_description was normal Lab_value .
However, immunohistochemical Diagnostic_procedure staining Diagnostic_procedure of the thymic Biological_structure tumor Biological_structure tissue Biological_structure revealed partial Lab_value anti Diagnostic_procedure - ACTH Diagnostic_procedure antibody Diagnostic_procedure positivity Lab_value .
The tumor Coreference was therefore determined to be ectopically Detailed_description producing Detailed_description ACTH Detailed_description .
The patient underwent chemotherapy Medication with cisplatin Medication and irinotecan Medication , but the continuation of chemotherapy was problematic Detailed_description due Detailed_description to Detailed_description a Detailed_description lack Detailed_description of Detailed_description tolerance Detailed_description .
Treatment for hypertension Sign_symptom and diabetes Disease_disorder caused by the ectopic Disease_disorder ACTH Disease_disorder syndrome Disease_disorder was initiated, as was treatment with zoledronic Medication acid Medication for bone Biological_structure metastasis Sign_symptom .
The patient was referred Clinical_event to the Endocrine Nonbiological_location Center Nonbiological_location at Nonbiological_location our Nonbiological_location hospital Nonbiological_location after Date 3 Date months Date due to a sensation Sign_symptom of Sign_symptom weakness Sign_symptom and the worsening of his hyperglycemia Sign_symptom .
A physical Diagnostic_procedure examination Diagnostic_procedure revealed hypertension Sign_symptom , a subcutaneous Detailed_description mass Sign_symptom that was palpable Detailed_description in the anterior Biological_structure chest Biological_structure , and redness Sign_symptom and swelling Sign_symptom of the left Biological_structure lower Biological_structure leg Biological_structure without fever Sign_symptom , respiratory Sign_symptom symptoms Sign_symptom , hypoxemia Sign_symptom , or abnormal Sign_symptom chest Sign_symptom sounds Sign_symptom .
The oxygen Diagnostic_procedure saturation Diagnostic_procedure by pulse Detailed_description oximeter Detailed_description in room Detailed_description air Detailed_description and was 97% Lab_value and his respiratory Diagnostic_procedure rate Diagnostic_procedure was 13 Lab_value breaths Lab_value per Lab_value minute Lab_value .
Among the laboratory Diagnostic_procedure findings Diagnostic_procedure , the white Diagnostic_procedure blood Diagnostic_procedure cell Diagnostic_procedure and neutrophil Diagnostic_procedure counts, and blood Diagnostic_procedure sugar Diagnostic_procedure , triglyceride Diagnostic_procedure , and low Diagnostic_procedure - density Diagnostic_procedure lipoprotein Diagnostic_procedure cholesterol Diagnostic_procedure levels were found to be elevated Lab_value , and the patient's potassium Diagnostic_procedure level was decreased Lab_value to 2.8 Lab_value mEq/L.
The patient's lactate Diagnostic_procedure dehydrogenase Diagnostic_procedure ( 468 Lab_value IU/L Lab_value ), beta Diagnostic_procedure - D Diagnostic_procedure glucan Diagnostic_procedure ( 370.8 Lab_value pg/mL Lab_value ), ACTH Diagnostic_procedure ( 354.1 Lab_value pg/mL Lab_value ), and cortisol Diagnostic_procedure ( 49.1 Lab_value μg/dL Lab_value ) levels were also elevated Lab_value .
The patient's serum Diagnostic_procedure was negative Lab_value for aspergillus Diagnostic_procedure , candida Diagnostic_procedure , and cryptococcus Diagnostic_procedure antigens Diagnostic_procedure ; a cytomegalovirus Diagnostic_procedure pp65 Diagnostic_procedure antigenemia Diagnostic_procedure test Diagnostic_procedure also yielded a negative Lab_value result.
These data suggested that the increased production of ACTH by the tumor, along with the progression of the disease, had promoted the elevation of the patient's serum levels of ACTH and cortisol.
Computed Diagnostic_procedure tomography Diagnostic_procedure ( CT Diagnostic_procedure ) revealed the progression Sign_symptom of Sign_symptom the Sign_symptom disease Sign_symptom in the both thymic Biological_structure and metastatic Detailed_description bone Biological_structure lesions Sign_symptom , along with the multiple Detailed_description ground Texture - glass Texture opacities Sign_symptom in both Biological_structure lungs Biological_structure (Fig.1, ​2).
The patient underwent bronchoalveolar Diagnostic_procedure lavage Diagnostic_procedure ( BAL Diagnostic_procedure ) in the right Biological_structure B5 Biological_structure segment Biological_structure with 150 Detailed_description mL Detailed_description saline Detailed_description , and 62.7% Lab_value of Lab_value the Lab_value BAL Lab_value fluid Lab_value was Lab_value recovered Lab_value .
The cell Diagnostic_procedure count Diagnostic_procedure in the BAL Detailed_description fluid Detailed_description was 0.61×105 Lab_value per Lab_value mL Lab_value , and the cell Diagnostic_procedure differentiation Diagnostic_procedure in the BAL Detailed_description fluid Detailed_description was 17.0% Lab_value macrophages Lab_value , 81.0% Lab_value lymphocytes Lab_value , and 2.0% Lab_value neutrophils Lab_value , with a CD Lab_value 4/8 Lab_value ratio Lab_value of Lab_value 0.57 Lab_value .
Gram Diagnostic_procedure , Ziehl Diagnostic_procedure - Neelsen Diagnostic_procedure , and Grocott Diagnostic_procedure staining Diagnostic_procedure were all negative Lab_value .
A polymerase Diagnostic_procedure chain Diagnostic_procedure reaction Diagnostic_procedure revealed that the patient's BAL Detailed_description fluid Detailed_description was positive Lab_value for Pneumocystis Diagnostic_procedure jirovecii Diagnostic_procedure .
PCP Disease_disorder was diagnosed based on the above results.
The patient was treated with sulfamethoxazole/trimethoprim Medication ( 12 Dosage g/day Dosage ) for 3 Duration weeks Duration .
Anti Therapeutic_procedure - cortisol Therapeutic_procedure therapy Therapeutic_procedure with metyrapone Medication was also initiated at the same time with a small Dosage dose Dosage to slowly correct the hypercortisolemia Disease_disorder .
Intensive insulin Medication therapy, potassium Medication supplementation were initiated, while cefazolin Medication was administered to treat cellulitis Disease_disorder of the left Biological_structure lower Biological_structure leg Biological_structure .
The patient's PCP Disease_disorder fully improved without the exacerbation Sign_symptom of his respiratory Diagnostic_procedure status Diagnostic_procedure .
Thereafter, we continued to administer sulfamethoxazole/trimethoprim Medication at a prophylactic Dosage dose Dosage .
The metyrapone Medication dosage was gradually increased from 250 Dosage mg/day Dosage , and the blood Diagnostic_procedure cortisol Diagnostic_procedure value was observed to decline Lab_value slowly Lab_value (Fig.3).
In order to prevent hypocortisolemia, the patient was temporarily Detailed_description treated with hydrocortisone Medication .
After an improvement of his left Biological_structure lower Biological_structure leg Biological_structure cellulitis Disease_disorder , PCP Disease_disorder , and hyperglycemia Disease_disorder , the patient underwent laminectomy Therapeutic_procedure and radiation Therapeutic_procedure therapy Therapeutic_procedure for spinal Disease_disorder cord Disease_disorder compression Disease_disorder , which had been caused by a metastatic Detailed_description spinal Biological_structure tumor Sign_symptom .
Octreotide Medication therapy was initiated, and he was discharged Clinical_event on the 68th Date day Date of hospitalization.