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• A 59 year old lady presented to the Endocrine Clinic with acromegalic appearances. ! • Past Medical History: Hypertension, glaucoma, subtotal thyroidectomy for multicystic thyroid • Drug History: levothyroxine, lisinopril, atenolol ! Course of events: • MRI revealed a pituitary macroadenoma 20×18×18 mm. • Repeat dynamic evaluation showed inadequate GH suppression (initially normal), in keeping with Acromegaly. ! ! ! ! ! ! ! • She was started on Cabergoline 500mcg twice weekly; later increased to 1mg twice weekly. • As IgF-1 remained elevated, Cabergoline later switched to Lanreotide with increasing doses. • Due to evolving visual defects, she was referred to MDT and underwent transphenoidal surgery. • Histology revealed a sparsely granulated somatotroph adenoma, ACTH-staining negative with Ki67<1%. Cytology showed monotonous neuroendocrine cells. • Pre-operative 9am serum cortisol = 287nmol/l. • Post-operative serum cortisol >1000 nmol/l on discharge. ! ! ! INITIAL PRESENTATION: Acromegaly

ACTH-dependent Cushing's syndrome unmasked following transphenoidal surgery for Acromegaly - the rare coexistence of dual endocrinopathies