Hypokalemia, metabolic alkalosis, and hypertension: Cushing's syndrome in a patient with metastatic prostate adenocarcinoma.

Ectopic adrenocorticotropic hormone (ACTH) and/or corticotropin-releasing hormone (CRH) are associated with a growing list of tumors. We report a 69-year-old white man with a history of high-grade prostate carcinoma and widely metastatic adenocarcinoma who presented with metabolic alkalosis, hypokalemia, and hypertension secondary to ectopic ACTH and CRH secretion. Laboratory values were consistent with hypokalemia and metabolic alkalosis. Markedly elevated serum cortisol (135 microg/dL), ACTH (1,387 pg/dL), CRH (69 pg/dL), and urine free cortisol (16,276 microg/24 h) levels were found. Chest computed tomographic (CT) scan showed small noncalcified parenchymal densities; however, bronchoscopy and bronchoalveolar lavage washings were unremarkable for a neoplastic process. Abdominal CT scan and magnetic resonance imaging showed multiple small liver lesions and multiple thoracic and lumbar intensities consistent with diffuse metastatic disease. Histological analysis of a biopsy specimen from the thoracic spine showed an undifferentiated adenocarcinoma consistent with a prostate primary tumor. The severe metabolic alkalosis secondary to glucocorticoid-induced excessive mineralocorticoid activity was treated with potassium supplements, spironolactone, and ketoconazole. In this case report, we describe an unusual tumor associated with ectopic ACTH and CRH production and the pharmacodynamic relationship of plasma cortisol levels and urinary cortisol excretion with ketoconazole treatment.

Increased sensitivity of acid-fast smears.

Evaluation of the centrifuges used in the mycobacteriology laboratory indicated a failure to develop sufficient relative centrifugal force for optimal concentration of acid-fast bacilli. Retrospective analysis of 14,509 specimens received between 1 July 1973 and 30 June 1975 and sedimented at 1,260 x g relative centrifugal force revealed a positive smear rate of 1.8% and a positive culture rate of 7.1%, with a correlation between positive paired smears and cultures of 25.2%. After increasing the relative centrifugal force from 1,260 x g to 3,800 x g at maximum radius, the positive smear and culture rates were 9.6 and 11.6%, respectively, with a correlation between positive paired smears and cultures of 82.4%. The sensitivity of acid-fast smears is directly related to the relative centrifugal force achieved while concentrating the specimen by centrifugation.