{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T16:24:40Z","timestamp":1772641480079,"version":"3.50.1"},"reference-count":17,"publisher":"BMJ","issue":"12","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,11,24]]},"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:p>A woman in her early 60s with a remote history of lung cancer presented with severe hypercortisolism, bilateral pulmonary consolidations and progressive cognitive decline. Extensive imaging and biopsies failed to identify a definitive adrenocorticotropic hormone (ACTH)-secreting tumour, but pulmonary nocardiosis was diagnosed, reflecting profound cortisol-induced immunosuppression. Management was further complicated by limited social supports and a history of unstable housing, raising concerns about access to advanced imaging and reliable follow-up. Despite medical therapy, hypercortisolism persisted, and she ultimately underwent bilateral adrenalectomy with marked improvement. This case illustrates the challenges of occult ectopic ACTH syndrome and underscores the importance of multidisciplinary management.<\/jats:p>","DOI":"10.1136\/bcr-2025-268512","type":"journal-article","created":{"date-parts":[[2025,12,19]],"date-time":"2025-12-19T08:40:15Z","timestamp":1766133615000},"page":"e268512","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Occult ectopic ACTH syndrome presenting with pulmonary nocardiosis and cognitive decline in a vulnerable patient"],"prefix":"10.1136","volume":"18","author":[{"given":"Bhavya","family":"Ancha","sequence":"first","affiliation":[{"name":"Internal Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jake","family":"Ermolovich","sequence":"additional","affiliation":[{"name":"Internal Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7787-027X","authenticated-orcid":false,"given":"Salem","family":"Harry-Hernandez","sequence":"additional","affiliation":[{"name":"Internal Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA"},{"name":"Pulmonary, Critical Care & Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,12,18]]},"reference":[{"key":"2026030403300509000_18.12.e268512.1","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1016\/j.tem.2023.12.003","article-title":"A clinical perspective on ectopic Cushing\u2019s syndrome","volume":"35","author":"Ragnarsson","year":"2024","journal-title":"Trends Endocrinol Metab"},{"key":"2026030403300509000_18.12.e268512.2","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1159\/000094323","article-title":"Ectopic ACTH syndrome","volume":"35","author":"Isidori","year":"2006","journal-title":"Front Horm Res"},{"key":"2026030403300509000_18.12.e268512.3","doi-asserted-by":"publisher","DOI":"10.1210\/jc.2004-2527"},{"key":"2026030403300509000_18.12.e268512.4","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1007\/s11102-019-00972-w","article-title":"Diagnostic utility of Gallium-68-somatostatin receptor PET\/CT in ectopic ACTH-secreting tumors: a systematic literature review and single-center clinical experience","volume":"22","author":"Varlamov","year":"2019","journal-title":"Pituitary"},{"key":"2026030403300509000_18.12.e268512.5","doi-asserted-by":"publisher","DOI":"10.1210\/jc.2009-2282"},{"key":"2026030403300509000_18.12.e268512.6","doi-asserted-by":"publisher","DOI":"10.1210\/jc.2005-1542"},{"key":"2026030403300509000_18.12.e268512.7","doi-asserted-by":"publisher","DOI":"10.1210\/jc.2003-030871"},{"key":"2026030403300509000_18.12.e268512.8","doi-asserted-by":"crossref","first-page":"847","DOI":"10.1016\/S2213-8587(21)00235-7","article-title":"Consensus on diagnosis and management of Cushing\u2019s disease: a guideline update","volume":"9","author":"Fleseriu","year":"2021","journal-title":"Lancet Diabetes Endocrinol"},{"key":"2026030403300509000_18.12.e268512.9","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1007\/BF03347735","article-title":"Disseminated nocardiosis in a patient with Cushing\u2019s syndrome","volume":"17","author":"Boscaro","year":"1994","journal-title":"J Endocrinol Invest"},{"key":"2026030403300509000_18.12.e268512.10","doi-asserted-by":"publisher","DOI":"10.1038\/srep43660"},{"key":"2026030403300509000_18.12.e268512.11","doi-asserted-by":"publisher","DOI":"10.1530\/EJE-19-0877"},{"key":"2026030403300509000_18.12.e268512.12","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1016\/j.amjsurg.2020.08.047","article-title":"Differences in outcomes of bilateral adrenalectomy in patients with ectopic ACTH producing tumor of known and unknown origin","volume":"221","author":"Szabo Yamashita","year":"2021","journal-title":"Am J Surg"},{"key":"2026030403300509000_18.12.e268512.13","doi-asserted-by":"publisher","DOI":"10.1210\/jc.2015-1818"},{"key":"2026030403300509000_18.12.e268512.14","unstructured":"Megha R , Wehrle CJ , Kashyap S . 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