Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms

A 70 year old man with a history of hairy cell leukemia (in remission) and depression presented with a 6week history of anorexia, weight loss (13.6 kg), and weakness. Initial evaluation revealed hypokalemia, hyperglycemia (HbA1c 7.2%), and a 1.9 cm left adrenal nodule. During hospitalization, he developed progressive encephalopathy, and cerebrospinal fluid (CSF) analysis showed hypoglycorrhachia (glucose 2 mg/dL), elevated protein (92 mg/dL), and lymphocytic pleocytosis (67 cells/μL). Blood and CSF cultures grew Cryptococcus neoformans, confirmed by India ink staining and antigen testing. Imaging revealed multifocal lacunar infarcts and diffuse cerebral edema. A 24hour urinary free cortisol level was markedly elevated (400 μg), confirming Cushing’s syndrome as the underlying cause of immunosuppression. Despite treatment with liposomal amphotericin B, the patient died due to complications of severe cerebral edema. This case highlights the interplay between hypercortisolism and opportunistic fungal infections, emphasizing the need for early recognition of Cushing’s syndrome in patients with unexplained weight loss and immunosuppression.

A 70 year old man with a history of hairy cell leukemia (in remission) and depression presented with a 6week history of anorexia, weight loss (13.6 kg), and weakness. Initial evaluation revealed hypokalemia, hyperglycemia (HbA1c 7.2%), and a 1.9 cm left adrenal nodule. During hospitalization, he developed progressive encephalopathy, and cerebrospinal fluid (CSF) analysis showed hypoglycorrhachia (glucose 2 mg/dL), elevated protein (92 mg/dL), and lymphocytic pleocytosis (67 cells/μL). Blood and CSF cultures grew Cryptococcus neoformans, confirmed by India ink staining and antigen testing. Imaging revealed multifocal lacunar infarcts and diffuse cerebral edema. A 24hour urinary free cortisol level was markedly elevated (400 μg), confirming Cushing’s syndrome as the underlying cause of immunosuppression. Despite treatment with liposomal amphotericin B, the patient died due to complications of severe cerebral edema. This case highlights the interplay between hypercortisolism and opportunistic fungal infections, emphasizing the need for early recognition of Cushing’s syndrome in patients with unexplained weight loss and immunosuppression.