Endocrine Abstracts

A 53-year-old lady of African origin presented to the emergency department with a 2 months history of watery diarrhoea associated with anorexia, general deterioration and weakness. She had lost 10 kg over 2 months. There was no history of recent travel abroad. Her past medical history included a cardiac arrest in 2000 (hypertrophic cardiomyopathy) and she had an internal defibrillator implanted for Brugada-like syndrome. She had hypertension since 1999 and it was noted that she was taking five different antihypertensives (olmesartan+amlodipine, spironolactone+altizide, moxonidine) and she was also on sotalol. On further questioning she also admitted to having hot flushes which she had attributed to the menopause. She had had an admission under the gastroenterologists 2 weeks previously and had a 24 h urine collection which had shown normal 5HIAA excretion however her chromogranin A was found to be elevated at 294 ng/ml (NR <100) and an octreotide scan had been requested which subsequently came back showing a chain of nodules overexpressing somatostatin receptors (subtype two and five) in the left para-aortic retroperitoneal region (in front of the left renal hilum). VIP and gastrin levels were normal. CT scan of the thorax was unremarkable. CT scan of the abdomen/pelvis showed no focal abnormality in the liver. Multiple mesenteric infra-centrimetric ganglions were seen. A 3.2 cm left adrenal mass was noted and there was also a right ovarian cyst. Three further urine collections were requested and in one collection the 5HIAA levels were elevated at 22.4 ng/24 h (NR <8). Catecholamine levels were normal.

It was planned for her to have a laparoscopic biopsy of one of the nodules noted on the octretide scan. However, at laparoscopy the surgeon could not visualize the nodules and removed the left adrenal mass. Subsequently the aldosterone level came back at 8.9 ng/dl (NR 4–20) and her renin level was <0.5 μUI/ml (NR 2.8–39.9), results compatible with a diagnosis of primary hyperaldosteronism. She came off all her anti-hypertensives. Unfortunately following her operation she developed a deep vein thrombosis and further investigations to look for the source of her carcinoid syndrome are on hold.