Crusted Scabies as a Complication of Severe Endogenous Hypercortisolism Due to Occult Ectopic ACTH Syndrome: A Case Report
This case report describes the first documented instance of crusted scabies occurring as a rare infectious complication in a patient with severe endogenous hypercortisolism caused by occult ectopic ACTH syndrome, highlighting the critical need to recognize atypical parasitic infections in immunocompromised individuals.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
The human body maintains a delicate balance of hormones, chemical messengers that regulate everything from metabolism to mood. Among these, cortisol is a vital hormone produced by the adrenal glands, helping the body respond to stress and manage blood sugar. However, when the body produces too much cortisol on its own, a condition known as Cushing syndrome develops. This excess hormone acts like a heavy blanket over the immune system, dulling its ability to fight off invaders. While this hormonal imbalance is known to cause weight gain, high blood pressure, and fragile skin, it also leaves the body vulnerable to infections that a healthy immune system would easily repel. One such infection is scabies, a skin condition caused by microscopic mites that burrow into the skin. In most people, this causes a mild, itchy rash, but in those with severely weakened immune systems, the infestation can become overwhelming, leading to a rare and severe form called crusted scabies, where the skin becomes thick, scaly, and teeming with millions of mites.
A team of doctors at a hospital in Istanbul recently documented a striking case where these two conditions collided in a single patient. They described a fifty-two-year-old man who arrived at the hospital with rapid weight gain, swelling in his legs, and the distinct physical features of Cushing syndrome, such as a rounded face and wide purple stripes on his abdomen. Blood tests confirmed that his body was producing far too much cortisol, driven by a signal from a hormone called ACTH. The medical team spent considerable effort searching for the source of this signal. They examined the pituitary gland in the brain and scanned the chest and abdomen for tumors, but despite finding a small, non-functioning spot on the pituitary, they could not locate the tumor responsible for the excessive hormone production. This led to a diagnosis of occult ectopic ACTH syndrome, a complex form of the disease where the source of the hormonal surge remains hidden from even the most advanced imaging tools.
While the doctors worked to manage the man's dangerous blood pressure and blood sugar levels, a new problem emerged on his skin. He developed thick, crusty patches on his hands and feet that were intensely itchy. A skin biopsy, a procedure where a small sample of tissue is examined under a microscope, revealed the true cause: the man was suffering from crusted scabies. The sample showed the skin was packed with scabies mites, a finding that is exceptionally rare in patients with naturally occurring high cortisol levels, as most previous reports of this severe infestation were linked to patients taking strong steroid medications. The medical team immediately placed the patient in isolation to prevent the highly contagious mites from spreading to others in the hospital.
Treating the patient required a two-pronged approach. First, the doctors attacked the infestation directly using a combination of a cream applied to the skin and a pill taken by mouth to kill the mites. As the treatment took effect, the thick crusts on his hands and feet began to disappear. Simultaneously, the team worked to lower the cortisol levels that had weakened his immune system in the first place. Because the source of the hormone could not be found and removed, the doctors performed surgery to remove both of the patient's adrenal glands, the organs responsible for making cortisol. This was done in two stages due to the patient's unstable condition during the first operation. Between the surgeries, they used medication to help control the hormone levels.
Over the following weeks, the patient's health improved significantly. His blood pressure and blood sugar stabilized, and the skin lesions from the scabies infection almost completely resolved. This case provides a clear example of how severe hormonal imbalances can create a perfect storm for rare infections. It highlights that when a patient with unexplained high cortisol levels develops unusual skin problems, doctors must consider severe parasitic infections as a possibility, even without a history of taking steroid drugs. The successful outcome relied on a coordinated effort between specialists in hormones, skin diseases, and surgery, proving that identifying and treating the underlying hormonal cause is just as critical as treating the infection itself.
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