Endocrine Abstracts

Section: Case history: 73-year old gentleman referred from GP with a two month history of worsening dizziness, malaise, postural hypotension and general deterioration and spiking pyrexia ranging 38-40°C over 3 weeks. PMH of NSCLC T2b N0- left lower lobectomy & chemotherapy 3 years prior.

Section: Investigations and treatment: At re-presentation his CT TAP showed bilateral bulky adrenal glands but no other abnormality. The patient’s bloods showed mild raised inflammatory markers, at this time he treated as sepsis of unknown origin with antibiotics and fluid.

A SST test done as suspicion of adrenal insufficiency (given his postural hypotension) revealed flat response, however steroid and fludrocortisone started with marginal symptoms improvement. Meanwhile he had been treated with several courses of antibiotics, however all micro cultures were clear (including several sets of blood cultures). The patient’s CXR was normal as well as viral screen, autoimmune screen while Echocardiogram showed normal LV function and no valvular lesions. The CSF results revealed mild raised of protein the rest including PCR to TB, as well as flow cytometry/immunophenotyping all negative.

He had been commenced acyclovir as meningoencephalitis, though no evidence suggested this diagnosis.

Inpatient CT-TAP showed Progressive generalized enlargement of both adrenal glands. Peri-adrenal inflammatory change.

He had CT guided Adrenal biopsy which showed malignant cells in the adrenals, poorly differentiated; these are needle cores of fibrovascular tissue and some adipose tissue, widely infiltrated by a malignant appearing tumour. Non-necrotic.

Whilst an inpatient on the general medical ward, despite all supportive care progressive inexorable deterioration occurred. The patient was transferred to medical HDU as he deteriorated further. In spite of best supportive care he continues spiking fevers and died after cardiac arrest.

Section: Conclusions and points for discussion: His presentation with swinging pyrexia and malignant adrenal infiltration without necrosis or other evidence of metastatic disease or positive microbiology was difficult to explain. An atypical presentation of adrenal metastasis without radiological or histological evidence of necrosis or sepsis was the final working diagnosis. Post Mortem report is awaited.