Endocrine Abstracts

Section 1: Case history: A case of a 23-year-old lady with a known history of Perthes disease, pulmonary stenosis, bronchial asthma, primary hypothyroidism on levothyroxine and newly diagnosed hypertension on amlodipine, who presented to Accident and Emergency with symptoms of generalised lethargy, weakness of the upper and lower limbs, rapid onset of weight gain for 6 months, increasing abdominal girth and recurrent genital thrush.

Section 2: Investigations: On presentation, the patient was tachycardic (123 bpm), hypertensive (162/98 mmHG) and overweight (BMI 27.2 kg/m²). Further examination showed evidence of Cushingoid features (moon facies, central obesity, light purple abdominal striae of 1 cm in diameter and intra-scapular fat pad). Neurological examination revealed proximal myopathy and abdominal examination showed abdominal distension. Blood and urine investigations revealed elevated 24-h urinary cortisol (2182 nmol/24 h, N: 0–130), random cortisol of 800 nmol/l and ACTH level of <0.3 ng/l. The patient had hypokalaemia, an elevated DHEAS and androgen profile, with evidence of hypogonadism on pituitary hormone profile.

Section 3: Results and treatment: The patient was diagnosed with a large lobulated malignant adrenal carcinoma with direct involvement of the left renal vein and bilateral widespread metastatic lung lesions, after undergoing a computed tomography of thorax, abdomen and pelvis. On day three of her admission, she became acutely confused, agitated and verbally aggressive. She was intubated and ventilated in the Intensive Care Unit (ICU). Ketoconazole and etomidate were initiated at 400 mg three times daily and 42.86 mcg/kg per hour respectively. Her cortisol level was monitored 12-hourly and dexamethasone was initiated when cortisol dropped to 101 nmol/l. Upon initiation of etomidate, the haemoglobin gradually dropped, which investigation suggested was due to haemolysis and she was transfused. The dose of etomidate was gradually reduced and stopped on day four. She was later transferred to an endocrine tertiary centre where she underwent left adrenalectomy. Post-operatively, she was initiated on mitotane and her ketoconazole and dexamethasone were substituted to metyrapone and hydrocortisone.

Section 4: Conclusions and points for discussion: Our patient’s hypercortisolism was managed successfully with intravenous etomidate. This patient may have had haemolysis, which has been suggested to be a side effect of the propylene glycol in the preparation of etomidate. Few previous case reports discuss etomidate’s use for acute psychosis due to a glucocorticoid-secreting adrenal carcinoma. It is important to remember Cushing’s Syndrome as a cause of acute psychosis and investigate further if suspected.