Ectopic ACTH syndrome secondary to small-cell oropharyngeal cancer

A woman in her 80s with known metastatic small-cell oropharyngeal cancer was admitted after a fall. There was proximal limb weakness with hypertension, metabolic alkalosis, hypokalaemia and hyperglycaemia. CT scans revealed progression of her cancer with enlarging liver and lung metastases. Her admission was complicated by delirium and progressive dysphagia relating to her primary oropharyngeal malignancy. Cortisol and adrenocorticotropic hormone (ACTH) were markedly raised and were not suppressed after overnight and high-dose dexamethasone tests. Typical clinical features of Cushing's syndrome were absent. She was diagnosed with ectopic ACTH syndrome secondary to small-cell oropharyngeal cancer. Metyrapone and spironolactone were commenced; however, the patient deteriorated, and a decision was made to prioritise her comfort over escalating treatment.