J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 8, Number 8, August 2017, pages 259-263

A Case of Transient Hypercortisolism Simultaneously Occurring With the Syndrome of Inappropriate Antidiuretic Hormone Secretion Induced by Olanzapine

**Table 1.** Laboratory Findings on Admission
PRA: plasma renin activity, ADH: antidiuretic hormone or vasopressin. U-Na and U-K indicate Na and K in the urine, respectively.
Urinalysis
Protein	±
Glucose	-
Ketone bodies	-
Bilirubin	-
Blood cell count
WBC	15,100/µL
RBC	394 × 10⁴/µL
Hb	11.7 g/dL
Plt	28.2 × 10⁴/µL
Blood chemistry
T-bil	0.9 mg/dL
AST	30 U/L
ALT	11 U/L
LDH	368 U/L
NH3	79 µg/dL
ALP	163
CK	249 U/L
T-cho	150 mg/dL
TG	43 mg/dL
TP	5.2 g/dL
Alb	2.9 g/dL
BUN	10.2 mg/dL
Cr	0.36 mg/dL
Na	110.3 mEq/L
K	2.67 mEq/L
Cl	67 mEq/L
Ca	7.2 mg/dL
IP	3.0 mg/dL
Mg	1.9 mg/dL
Osm	226 mOsm/kg
Glu	125 mg/dL
HbA1c	5.8%
Serological test
CRP	0.6 mg/dL
Endocrine examination
Free T3	1.6 pg/mL
Free T4	1.6 ng/dL
TSH	0.541 µIU/mL
ACTH	122 pg/mL
Cortisol	35.9 µg/dL
PRA	0.2 ng/mL/h
PAC	133 pg/mL
ADH	5.9 pg/mL
Urine test
Na	68.8 mEq/L
K	47.7 mEq/L
Osm	435 mOsm/kg
Blood gas analysis
pH	7.555
PCO₂	40 mm Hg
PO₂	113 mm Hg
HCO₃^-	35.4 mEq/L
BE	11.9 mmol/L

Table 1. Laboratory Findings on Admission

PRA: plasma renin activity, ADH: antidiuretic hormone or vasopressin. U-Na and U-K indicate Na and K in the urine, respectively.

Urinalysis

Protein

Glucose

Ketone bodies

Bilirubin

Blood cell count

WBC

15,100/µL

RBC

394 × 10⁴/µL

11.7 g/dL

Plt

28.2 × 10⁴/µL

Blood chemistry

T-bil

0.9 mg/dL

AST

30 U/L

ALT

11 U/L

LDH

368 U/L

NH3

79 µg/dL

ALP

163

249 U/L

T-cho

150 mg/dL

43 mg/dL

5.2 g/dL

Alb

2.9 g/dL

BUN

10.2 mg/dL

0.36 mg/dL

110.3 mEq/L

2.67 mEq/L

67 mEq/L

7.2 mg/dL

3.0 mg/dL

1.9 mg/dL

Osm

226 mOsm/kg

Glu

125 mg/dL

HbA1c

5.8%

Serological test

CRP

0.6 mg/dL

Endocrine examination

Free T3

1.6 pg/mL

Free T4

1.6 ng/dL

TSH

0.541 µIU/mL

ACTH

122 pg/mL

Cortisol

35.9 µg/dL

PRA

0.2 ng/mL/h

PAC

133 pg/mL

ADH

5.9 pg/mL

Urine test

68.8 mEq/L

47.7 mEq/L

Osm

435 mOsm/kg

Blood gas analysis

7.555

PCO₂

40 mm Hg

PO₂

113 mm Hg

HCO₃^-

35.4 mEq/L

11.9 mmol/L

**Table 2.** Urinary Cortisol in 24-H Urine Collection, and Diurnal Variations in Plasma ACTH and Serum Cortisol
	Sixth day	34th day
Her urine was collected and stored in 24-h collection containers for the measurement of urinary cortisol levels.
ACTH (pg/mL)	66.9	44.4	19.3	2.1
Cortisol (µg/dL)	23.0	16.0	12.5	4.7
Urinary cortisol (µg/day) (11.2 - 80.3)	655	96.6

Table 2. Urinary Cortisol in 24-H Urine Collection, and Diurnal Variations in Plasma ACTH and Serum Cortisol

Sixth day

34th day

8:00

23:00

8:00

23:00

Her urine was collected and stored in 24-h collection containers for the measurement of urinary cortisol levels.

ACTH (pg/mL)

66.9

44.4

19.3

2.1

Cortisol (µg/dL)

23.0

16.0

12.5

4.7

Urinary cortisol (µg/day) (11.2 - 80.3)

655

96.6

**Table 3.** Low- and High-Dose Dexamethasone Suppression Tests
	8:00
Low-dose overnight DST: 1 mg of dexamethasone was taken orally at 23:00, and her blood was drawn at 8:00 on the next day for plasma ACTH and serum cortisol measurements. High-dose overnight DST: 8 mg of dexamethasone was taken orally at 23:00, and her blood was drawn at 8:00 on the next day for plasma ACTH and serum cortisol measurements.
Overnight 0.5 mg test on the 10th day
ACTH (pg/mL)	25.9
Cortisol (µg/dL)	18.7
Overnight 8 mg test on the 14th day
ACTH (pg/mL)	2.1
Cortisol (µg/dL)	3.1

Table 3. Low- and High-Dose Dexamethasone Suppression Tests

8:00

Low-dose overnight DST: 1 mg of dexamethasone was taken orally at 23:00, and her blood was drawn at 8:00 on the next day for plasma ACTH and serum cortisol measurements. High-dose overnight DST: 8 mg of dexamethasone was taken orally at 23:00, and her blood was drawn at 8:00 on the next day for plasma ACTH and serum cortisol measurements.

Overnight 0.5 mg test on the 10th day

ACTH (pg/mL)

25.9

Cortisol (µg/dL)

18.7

Overnight 8 mg test on the 14th day

ACTH (pg/mL)

2.1

Cortisol (µg/dL)

3.1

**Table 4.** Corticotropin-Releasing Hormone Stimulation Test
	0 min	15 min	30 min	60 min	90 min	120 min
Human CRH (Corticorelin; hCRH “TANABE”) at 100 µg was injected as an intravenous bolus. Blood samples for ACTH and cortisol were drawn 0, 15, 30, 60, 90, and 120 min after the CRH injection. The CRH test revealed an increase in plasma ACTH and cortisol levels. An elevation in ACTH occurred after 15 - 60 min and the highest level was reached 30 min after the CRH injection, while plasma cortisol levels peaked 60 min after the CRH injection. The plasma ACTH peak value (88.6 pg/mL at 30 min) was more than 1.5-fold higher than the previous value (24.2 pg/mL). Similar endocrine responses to those observed in patients with pituitary-dependent Cushing’s syndrome were noted. * indicates the top value.
ACTH (pg/mL)	24.2	77.1	88.6*	71.8	39.7	29.3
Cortisol (µg/dL)	16.0	23.7	27.2	29.3*	23.0	20.5

Table 4. Corticotropin-Releasing Hormone Stimulation Test

0 min

15 min

30 min

60 min

90 min

120 min

Human CRH (Corticorelin; hCRH “TANABE”) at 100 µg was injected as an intravenous bolus. Blood samples for ACTH and cortisol were drawn 0, 15, 30, 60, 90, and 120 min after the CRH injection. The CRH test revealed an increase in plasma ACTH and cortisol levels. An elevation in ACTH occurred after 15 - 60 min and the highest level was reached 30 min after the CRH injection, while plasma cortisol levels peaked 60 min after the CRH injection. The plasma ACTH peak value (88.6 pg/mL at 30 min) was more than 1.5-fold higher than the previous value (24.2 pg/mL). Similar endocrine responses to those observed in patients with pituitary-dependent Cushing’s syndrome were noted. * indicates the top value.

ACTH (pg/mL)

24.2

77.1

88.6*

71.8

39.7

29.3

Cortisol (µg/dL)

16.0

23.7

27.2

29.3*

23.0

20.5