Rihab Laamouri

Background: Cushing’s disease (CD), caused by an ACTH-secreting pituitary adenoma, remains one of the most challenging endocrine disorders to diagnose and treat. The coexistence of resistant hypertension, metabolic complications, and complex vascular anatomy such as “kissing carotids” further complicates management. Case Presentation: We report a 40-year-old man with long-standing hypertension referred for evaluation of resistant blood pressure. Physical examination revealed classical Cushingoid features. Endocrine testing confirmed ACTH-dependent Cushing’s syndrome. Pituitary MRI was limited by a rare vascular variant medialized internal carotid arteries (“kissing carotids”) which obscured visualization of the adenoma. The patient underwent endoscopic transsphenoidal surgery in a specialized neurosurgical center, confirming a corticotroph adenoma. Postoperatively, cortisol levels normalized, and metabolic and cardiovascular comorbidities markedly improved. Conclusion: This case highlights the diagnostic and therapeutic complexity of ACTH-dependent Cushing’s disease with challenging pituitary anatomy. Expert multidisciplinary management remains essential to achieve remission and prevent long-term sequelae.

Background: Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycemia in neonates and children. Prompt diagnosis and treatment is important to avoid long-term neurological damage. In diazoxide-unresponsive cases, somatostatin receptor analogs are used in second line. Pasireotide, which has a higher affinity for the somatostatin receptor 5 than first-generation somatostatin analogs, was trialed in a pediatric patient with hyperinsulinism. Case description: The patient presented at the age of 8 years with recurrent episodes of nonfasting hypoglycemia and neuroglycopenic symptoms. A diagnosis of autonomous insulin secretion was biochemically confirmed by elevated levels of insulin (22.9 µUI/mL > 3 µUI/mL) and C-peptide (3.43 ng/mL > 0.6 ng/mL) during hypoglycemia (glucose 2.03 mmol/L). Glucose infusion rate to maintain euglycemia was 7 (mg/kg/min). The patient was initially treated by frequent feeding with carbohydrate-enriched formula and diazoxide 10 mg/kg/day. At the age of 12 years treatment with subcutaneous injections of octreotide was added because of recurrent hypoglycemia. Six months later and with parental consent, long acting pasireotide 40 mg every 28 days was initiated. Common side effects associated with pasireotide were carefully monitored, but did not occur. The patient was normoglycemic with a good growth rate, normal weight gain, and excellent neurodevelopment. Conclusion: This case study adds to findings reported previously suggesting that pasireotide may be a valuable option in second-line treatment of hyperinsulinism.