Endocrine Abstracts

54 year old lady presented to the endocrine clinic. She was diagnosed with breast cancer and right ovarian tumour at the same time in August 2015. She had right lumpectomy of breast and Salpingo-Oophorectomy in November 2015. She was not feeling very well for the last few weeks. She complained of extreme lethargy and tiredness. She had blood test done on 15th November 2016 that showed prolactin level at 2849 nmmol/l with negative macroprolactin. Hence, she was referred to the endocrine clinic. Her prolactin level was normal in February 2016 at 170 nmol/l.

She has not had any galactorrhoea. She has been menopausal for the last four years. She has a family history of hypothyroidism. She did not have any steroid replacement.

Her weight was 53.70 kg, her blood pressure was 95/60 mmHg and no postural drop. Her vision was normal to confrontation. She did not have any Cushingoid features.

Her blood results came back on the same evening and showed a very low cortisol level, less than 20 nmol/l. Her prolactin level was normal at 426 milliunit/l, TSH 0.5 milliunit/l, T₄ 11.6 pmol/l, IGF-1 25.1 nmol/l, Na 140 mmol/l, K 4.6 mmol/l. She had Short Synacthen test next day and it showed very low base line cortisol <20 nmmol/l, after Synacthen, cortisol was 52 and 72 nmol/l at 30 min and 60 min respectively. Her ACTH fluctuates between <5 and 35.0 ng/l. We arranged long synacthen and results are following.

The delayed rise in cortisol, in keeping with secondary adrenal insufficiency but one of her ACTH came back as 35 ng/l. So currently she is on prednisolone 3 mg and fludrocortisone 25 μg and imaging for her pituitary and adrenals are requested. Her renin aldosterone ratio is pending.

The presentation will focus on the following questions:

1. What treatment should be offered to the patient on the basis of her result for short synacthen test and long synacthen test and ACTH? What is the diagnosis, is it primary or secondary adrenal insufficiency?

2. Are additional investigations required before starting on steroid replacement?

3. Is long synacthen test helpful in this case?