A 45-year-old man with Cushing's disease undergoes pituitary surgery but has persistent hypercortisolism. Per current guidelines, bilateral adrenalectomy is performed. Which complication unique to this situation must be closely monitored for in follow-up?

• A Empty sella syndrome
• B Sheehan's syndrome
• C Addison's disease with preserved ACTH
• D Nelson's syndrome ✓

Explanation

Nelson's syndrome occurs after bilateral adrenalectomy in Cushing's disease: removal of cortisol abolishes feedback inhibition on the residual ACTH-secreting pituitary adenoma, which then expands aggressively causing hyperpigmentation and mass effects (headache, visual field defects). It occurs in 8–38% of patients post-adrenalectomy. Empty sella and Sheehan's syndrome are unrelated to this sequence. Addison's disease is certainly created by the adrenalectomy, but ACTH will be markedly elevated (not preserved at normal levels) due to loss of negative feedback.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.