The course of gout in a patient with Cushing’s disease after successful surgical treatment

Endogenous  hypercortisolism  is a severe endocrine  disease characterized by prolonged  exposure to excessive amounts of glucocorticoid hormones, accompanied by a wide range of symptoms and complications, including immunosuppression. Timely surgical treatment in most cases allows to save the patient’s life, significantly improve its quality. However, restoration of the normal concentration of glucocorticoid  hormones can become a trigger factor in the development or exacerbation of autoimmune and auto-inflammatory diseases. We present a clinical case of atypical gout in a patient with hypercortisolism and a progressive increase in symptoms of the disease after successful surgical treatment for Cushing’s disease and achieving stable remission. The issues of diagnosis and treatment of this group of autoinflammatory diseases are highlighted, the leading clinical and radiological  symptoms are considered, the differential diagnosis  of microcrystalline (metabolic) arthritis is presented. Despite the widespread, the diagnosis and treatment of this group of diseases still cause difficulties for specialists. A competent choice of drug therapy allows to fully control diseases considered in the article, including when they are combined, and thereby improve the quality of life of the patient.

1. Golounina OO, Belaya ZE, Rozhinskaya LYa, et al. Clinical and laboratory characteristics and results of treatment of patients with ACTH-producing neuroendocrine tumors of various localization. Therapeutic Archive. 2021;93(10):1171-1178. (In Russ.). doi: https://doi.org/10.26442/00403660.2021.10.201102

2. Belaya Z, Golounina O, Melnichenko G, et al. Clinical course and outcome of patients with ACTH-dependent Cushing's syndrome infected with novel coronavirus disease-19 (COVID-19): case presentations. Endocrine. 2021;72(1):12-19. doi: https://doi.org/10.1007/s12020-021-02674-5

3. Barskova VG, Eliseyev MS, Denisov IS. Experience in treating a gout patient with adrenal insufficiency. Modern Rheumatology Journal. 2012;6(4):61-65. (In Russ.). doi: https://doi.org/10.14412/1996-7012-2012-765

4. Chikina MN, Eliseev MS, Zhelyabina OV. Comparison of the efficacy and safety of various anti-inflammatory drugs in urate-lowering therapy initiation in patients with gout (preliminary data). Modern Rheumatology Journal. 2021;15(2):50-56. (In Russ.). doi: https://doi.org/10.14412/1996-7012-2021-2-50-56.

5. Yakushiji F, Kita M, Hiroi N, et al. Exacerbation of rheumatoid arthritis after removal of adrenal adenoma in Cushing's syndrome. Endocr J. 1995;42(2):219-223. doi: https://doi.org/10.1507/endocrj.42.219

6. Uthman I, Senecal JL. Onset of rheumatoid arthritis after surgical treatment of Cushing's disease. J Rheumatol. 1995;22(10):1964-1966.

7. Bongetta D, Zoia C, Lombardi F, et al. Systemic sarcoidosis unmasked by Cushing's disease surgical treatment. Case Rep Med. 2016;2016:1-3. doi: https://doi.org/10.1155/2016/6405840

8. Diernaes JEF, Bygum A, Poulsen PL. Unmasking sarcoidosis following surgery for Cushing disease. Dermatoendocrinol. 2016;8(1):e983688. doi: https://doi.org/10.4161/derm.29855

9. Norena-Rengifo BD, Gomez-Corrales JD, Roman-Gonzalez A. Unmasking of sarcoidosis after successful management of Cushing's syndrome. Cureus. 2019;11(1):e3896. doi: https://doi.org/10.7759/cureus.3896

10. Noguchi Y, Tamai H, Fujisawa K, et al. Systemic lupus erythematosus after pituitary adenomectomy in a patient with Cushing's disease. Clin Endocrinol. 1998;48(5):670-672. doi: https://doi.org/10.1046/j.1365-2265.1998.00489.x

11. Muzulu SI., Howlett TA. Polymyalgia rheumatica presenting after successful treatment of Cushing's disease. Rheumatology. 1998;37(7):804-805. doi: https://doi.org/10.1093/rheumatology/37.7.804

12. Colao A, Pivonello R, Faggiano A, et al. Increased prevalence of thyroid autoimmunity in patients successfully treated for Cushing's disease. Clin Endocrinol (Oxf). 2000;53(1):13-19. doi: https://doi.org/10.1046/j.1365-2265.2000.01018.x

13. Melnichenko GA, Dedov II, Belaya ZE, et al. Cushing's disease: the clinical features, diagnostics, differential diagnostics, and methods of treatment. Problems of Endocrinology. 2015;61(2):55-77 (In Russ.). doi: https://doi.org/10.14341/probl201561255-77

14. Hench PS. Effects of cortisone acetate and pituitary ACTH on rheumatoid arthritis, rheumatic fever and certain other conditions: A Study in Clinical Physiology. Arch Intern Med (Chic). 1950;85(4):545-666. doi: https://doi.org/10.1001/archinte.1950.00230100002001

15. Daoussis D, Kordas P, Varelas G, et al. ACTH vs steroids for the treatment of acute gout in hospitalized patients: a randomized, open label, comparative study. Rheumatol Int. 2022;42(6):949-958. doi: https://doi.org/10.1007/s00296-022-05128-x

16. Eliseev MS. ACR management guidelines for the treatment of gout: What's new and what's controversial. Rheumatology Science and Practice. 2021;59(2):129-133. (In Russ.). doi: https://doi.org/10.47360/1995-4484-2021-129-133

17. Yu J, Qiu Q, Liang L, et al. Prophylaxis of acute flares when initiating febuxostat for chronic gouty arthritis in a real-world clinical setting. Modern Rheumatology. 2018;28(2):339-344. doi: https://doi.org/10.1080/14397595.2017.1318467

18. Eliseev MS. Gout classification criteria (ACR/EULAR GUIDELINES). Rheumatology Science and Practice. 2015;53(6):581-585. (In Russ.). doi: https://doi.org/10.14412/1995-4484-2015-581-585

19. Eliseev MS, Vladimirov SA. The prevalence and clinical features of gout and calcium pyrophosphate deposition disease in patients with acute arthritis. Rheumatol Sci Pract. 2015;53(4):375. (In Russ). doi: https://doi.org/10.14412/1995-4484-2015-375-378

20. Kudaeva FM, Vladimirov SA, Eliseev MS, et al. The clinical manifestations of calcium pyrophosphate crystal deposition disease. Rheumatology Science and Practice. 2014;52(4):405-409. (In Russ.). doi: https://doi.org/10.14412/1995-4484-2014-405-409

21. Eliseev MS., Chikalenkova NA., Barskova VG. Clinical features of gout in women: the results of a comparative study. Rheumatology Science and Practice. 2014;52(2):178-182. (In Russ.). doi: https://doi.org/10.14412/1995-4484-2014-178-182

22. Reuss-Borst M, Tausche A-K. Gicht und Calciumpyrophosphat-Dihydrat-Arthropathie («Pseudogicht») — ein Update. Dtsch med Wochenschr. 2018;143(16):1157-1166. doi: https://doi.org/10.1055/a-0504-5684

23. Georginova OA, Gorbunov RM, Kadrev AV, Plisyuk AG. Verification difficulties of diagnosis in a patient with uratosis and pyrophosphate arthropathy. Therapy. 2019;3(29):136-139. (In Russ.). doi: https://doi.org/10.18565/therapy.2019.3.136-139

24. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2010;69(9):1580-1588. doi: https://doi.org/10.1136/ard.2010.138461

25. Vladimirov SA, Eliseev MS, Radenska-Lopovok SG, Barskova VG. Differentsial'naya diagnostika revmatoidnogo artrita i podagry. Modern Rheumatology Journal. 2008;2(4):39-41. (In Russ.). doi: https://doi.org/10.14412/1996-7012-2008-505

26. Zhang W, Doherty M, Pascual E, et al. EULAR recommendations for calcium pyrophosphate deposition. Part II: Management. Ann Rheum Dis. 2011;70(4):571-575. doi: https://doi.org/10.1136/ard.2010.139360

27. Eliseev MS, Zhelyabina OV, Chikina MN. Age-related features of calcium pyrophosphate deposition disease. Rheumatology Science and Practice. 2019;57(6):651-656. (In Russ.). doi: https://doi.org/10.14412/1995-4484-2019-651-656

28. Filippou G, Filippucci E, Mandl P, Abhishek A. A critical review of the available evidence on the diagnosis and clinical features of CPPD: do we really need imaging? Clin Rheumatol. 2021;40(7):2581-2592. doi: https://doi.org/10.1007/s10067-020-05516-3

29. Tanikawa H, Ogawa R, Okuma K, et al. Detection of calcium pyrophosphate dihydrate crystals in knee meniscus by dualenergy computed tomography. J Orthop Surg Res. 2018;13(1):73. doi: https://doi.org/10.1186/s13018-018-0787-0

30. Sotniczuk M, Nowakowska-Ptaza A, Wronski J, et al. The clinical utility of dual-energy computed tomography in the diagnosis of gout — A cross-sectional study. J Clin Med. 2022;11(17):5249. doi: https://doi.org/10.3390/jcm11175249