Etomidate Monotherapy for Perioperative Control of Hypercortisolism in a Mitotane-Intolerant Patient With Adrenocortical Carcinoma: A Case Report

Endogenous Cushing syndrome is a metabolic syndrome that results from the excessive production of cortisol from the adrenal gland.Hypercortisolism can result in serious complications, such as hypertension, myocardial ischemia, glucose intolerance, immunosuppression, and electrolyte disturbances.The mainstay of treatment is surgical resection for resectable tumors, along with pharmacological therapy in selected cases, because severe hypercortisolism often requires prompt medical stabilization before definitive surgical management can be safely performed.We report a 34-year-old male patient who presented with generalized weakness, peripheral numbness, and palpitations and was found to have severe hypokalemia, metabolic alkalosis, and high levels of cortisol.Diagnostic laboratory tests showed adrenocorticotropic hormone (ACTH)-independent Cushing syndrome, which was confirmed with magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging.Etomidate was used to control hypercortisolism preoperatively as a bridge to definitive surgical resection of right adrenal adenocarcinoma after failure of a course of mitotane therapy.Sub-anesthetic doses of etomidate dramatically lowered cortisol levels, reduced the need for potassium replacement, and controlled blood pressure with fewer side effects.