Case 1

>A boy aged 7 years was referred to the endocrine clinic with a history of growth failure associated with obesity. Over the past two years his weight had increased from the 50th to the 97th centile with height falling from the 10th to the 3rd centile. He had no history of note apart from mild atopy and chronic catarrh, for which he had been prescribed 0.1% betamethasone nasal drops.

On examination he was cushingoid with normal prepubertal genitalia. His blood pressure was 165/75 mm Hg (>95th centile for age). Pituitary Cushing's syndrome was diagnosed clinically and he was admitted for endocrine assessment. We expected to find high serum cortisol concentrations, but cortisol was undetectable (<24 nmol/l) and he did not respond to stimulation by insulin hypoglycaemia. Adrenocorticotrophic hormone was also undetectable. A 24 hour urine sample showed extremely low adrenal steroid metabolite concentrations, indicating severely impaired adrenal function. Computed tomography of the brain and adrenal glands showed …