Endocrine Abstracts

We report a case of a 43 year old lady who was referred by her general practitioner (GP) to the endocrine team with an 8 month history of extreme fatigue, difficulty losing weight, galactorrhoea and mild breast enlargement. She has two children aged 16 and 14, all well. Her background medical history included depression, asthma and hysterectomy for fibroids 3 years ago. Examination of all systems were unremarkable including visual fields to confrontation, fundoscopy and full neurological exam, except for a drop of milky discharge on expressing nipples and a palpable right thyroid nodule. She was investigated by means of a pituitary profile which showed prolactin of 768 mainly monomeric (upper limit 496), E2 <44 with the remainder of her pituitary screen being normal. A subsequent magnetic resonance imaging (MRI) scan showed a bulky pituitary gland but no definite lesion/adenoma. Her galactorrhoea subsided on cabergoline which was stopped at 6 weeks. She then reported bilateral galactorrhoea after cessation of cabergoline. It was a joint decision to take a wait and see approach, with repeated blood tests earlier if need be. Her thyroid ultrasound showed a 5 mm U3 nodule with FNAC reported as THY4. In view of the high suspicion of malignancy she was referred to the endocrine surgeon following endocrine MDT meeting. As part of her pre-operative work up, a chest x-ray showed an incidental finding of a possible mass in the right atrium. She was further investigated with a computed tomography (CT) scan of the neck, chest, abdomen and pelvis to assess the atrial mass and for routine staging. This showed a 5 mm hypo enhancing nodule in the thyroid isthmus with no evidence of malignancy, an incidental finding of a 7 mm left adrenal nodule and a 2.5 cm×2 cm soft tissue mass attached to the atrial septum suggestive of an atrial myxoma. An echocardiogram showed a strong possibility of atrial myxoma, hence she was referred to the cardiothoracic surgeons for further assessment and surgical excision after confirmation of normal urinary metanephrines. She is awaiting total thyroidectomy in view of cytology findings (THY4).

Conclusion: The importance of a good thorough history and examination of all systems is paramount as it can reveal other incidental findings which may well then have an impact on future comorbidities, mortality and ones life.