case report
New psychosis led to antipsychotics. Ectopic ACTH from cervical cancer was the driver.
2026-06-23
New psychosis led to antipsychotics. Ectopic ACTH from cervical cancer was the driver.
A recurrence and a change in behavior
A 39-year-old Japanese woman was undergoing treatment for recurrent small-cell carcinoma of the cervix (SCCC). After initially undergoing a radical trachelectomy to preserve her fertility, the cancer had spread to her lymph nodes and liver. Despite multiple rounds of chemotherapy, the disease progressed. 10 months after her first recurrence, her tumor markers rose and CT scans showed the liver metastases were growing.
At this time, her behavior changed. On the day her scan results were confirmed, she began refusing medical treatment. The next day, she began locking herself in the bathroom and seemingly casting spells. By the third day, she was making delusional statements, claiming she had already fought the cancer and won, and that an "evil spirit" inhabited the hospital.
The psychiatric ward
Her husband, assisted by the police and emergency services, brought her to the hospital. She was in a state of hallucinating delusion and psychomotor agitation. She was involuntarily hospitalized in the psychiatry department. Doctors initiated treatment with the antipsychotic risperidone to manage her agitation.
While the agitation lessened, her delusions persisted. She exhibited grandiose behavior, expressing excessive gratitude to the staff and claiming she would win a Nobel Prize for her ideas. She began telling her husband she was being poisoned, while hiding these symptoms from the medical staff. Eventually, she began claiming she was "a god" and became so disoriented that she removed her own catheter, requiring physical restraint.
Clues in the blood
A medical workup was launched to find an organic cause. A brain MRI showed no tumors or pituitary issues. A spinal tap was normal, but an electroencephalography (EEG) showed generalized slow waves. The most significant finding appeared in her basic blood work: her potassium was dangerously low at 2.1 mmol/L.
Further testing revealed massive hormonal abnormalities. Her ACTH was 687 pg/mL and her serum cortisol was 98.3 μg/dL. Her urinary free cortisol was measured at 2,870 µg/L—nearly 30 times the upper limit of normal. The neuroendocrine tumor in her cervix was producing ectopic hormones, causing acute Cushing’s syndrome. The sudden flood of cortisol was poisoning her brain.
Treatment and final days
The diagnosis was reframed from primary psychosis to Cushing’s syndrome caused by ectopic ACTH production. She was given metyrapone, a medication to block cortisol synthesis. Within 24 hours, her cortisol levels dropped to 6.6 μg/dL. As the hormone levels normalized, her psychiatric symptoms vanished.
The delusions and grandiose statements stopped completely. The patient gained insight into her recent behavior, telling her doctors, "My previous condition was abnormal." Antipsychotics were discontinued. However, due to the advanced stage of her cancer and the rapid progression of the liver metastases, she was discharged for home hospice care. She died at home 58 days after her psychiatric symptoms first appeared.
The medical picture
Urinary free cortisol
2,870 µg/L (20-30x upper limit)
Adrenocorticotropic hormone (ACTH)
687 pg/mL
Serum cortisol
98.3 μg/dL
Serum potassium
2.1 mmol/L
Neural-specific enolase (NSE)
75.9 ng/mL
Adapted faithfully from the open-access case report: Frontiers in Oncology (PMC13038856). DOI: 10.3389/fonc.2026.1684861. Read the original at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13038856/.