Endocrine Abstracts

A 50-year-old peri-menopausal lady has had a background history of hypertension on single-agent antihypertensive medication (ACEI), chronic headache, recurrent collapses, and panic attacks for the past 14 years. She has been visited by her GP frequently and performed countless blood tests including FSH, LH, and TSH which confirmed that her symptoms were neither related to menopause nor hyperthyroidism. She also presented to the Emergency Department a dozen times and called paramedics 8 times for similar symptoms. She was diagnosed with panic attacks or investigated for meningitis. Her symptoms have never been resolved or getting better after discharge from the hospital. Unfortunately, her chronic catecholamines symptoms were controlled with anti-depressants and analgesics. Subsequently, she was relocated to a new place in 2014 and registered with a new GP for symptom relief medications. The GP reviewed her before issuing a repeat prescription and re-investigated the unresolved symptoms. 24-hour urine catecholamines were markedly elevated which were evident by urine volume of 3.7L, Noradrenaline 54327 nmol/24 hours (0–570 nmol/L), Adrenaline 78 nmol/24 hours(0–100nmol/l), urine dopamine 1468 nmol/24 hours (0–2500 nmol) respectively. Finally, she was referred to the endocrine clinic for further evaluation and management. She was a slim and well-presented lady with a slightly anxious disposition on examination. Her BP was 150/90 with a pulse rate of 100 beats /min. Hypertensive retinopathy grade 1 was detected in fundoscopy. There was no postural drop and no thyroid nodules. MRI adrenals showed 39 mm high intensity right adrenal lesion. Alpha blockade with Phenoxybenzamine was used before surgery. She underwent laparoscopic right adrenalectomy in January 2015 and the histology reported encapsulated tumour without lymphovascular invasion and low risk for malignancy. The adrenergic symptoms were entirely resolved postoperatively. She became normotensive and Urinary catecholamines were dramatically normalized although she required hydrocortisone replacement for a few months due to the suboptimal short synacthen test. It was stopped subsequently as her adrenal response has recovered fully thereafter. She has been followed up in endocrine outpatient clinic from 2015 to 2020 with 6-monthly urinary catecholamine and there is no biochemical as well as clinical features of pheochromocytoma relapse.

Discussion: The diagnosis of a very rare and potentially life-threatening endocrine tumour was made by a General Practitioner instead of an endocrinologist. This case also highlighted that the definitive treatment is not only curative and reducing cardiovascular risks, but also improving her quality of life.